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Asymptomatic Central Pontine Myelinolysis in a Pregnant Woman With Hodgkin Lymphoma

Published:December 07, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.11.021
      A 28-year-old primiparous woman at 27 gestational weeks with no medical or family history was referred for anemia associated with increased inflammatory markers. Medications included folic acid and oral iron therapy. The patient reported no symptoms, except for pruritus. Clinical examination revealed right-sided lymphadenopathy of the cervical anterior triangle. Laboratory examination showed microcytic normochromic anemia, hemoglobin 7.7 g/dL (normal >10.5), thrombocytosis 700 × 109/L (normal < 150), elevated C-reactive protein level 47.6 mg/L (normal <5), low serum albumin level 2.9 g/dL (normal >3.5), and normal blood electrolytes, creatinine level, liver functions tests, and lactate dehydrogenase (LDH) levels. Cervicothoracic magnetic resonance imaging (MRI) showed mediastinal and right-sided anterior cervical lymphadenopathies (size of the largest lymph nodes 6.1 × 3.2 × 6.7cm and 1.5 × 2.7 × 3.0 cm, respectively). Cervical lymph node biopsy led to a diagnosis of nodular sclerosis classical Hodgkin lymphoma. The patient had stage IIA disease according to as Ann Arbor/Cotswold. A suspected lesion of the pons on cervical spine images prompted brain MRI showing a hyperintense signal in the central pons on T2-weighted and fluid attenuated inversion recovery (FLAIR) images, with restriction in diffusion-weighted imaging (DWI), without contrast enhancement (Figure), highly suggestive of central pontine myelinolysis. She was given 6 cycles of ABVD chemotherapy combining adriamycin, bleomycin, vinblastine, and dacarbazine during pregnancy. At 36 gestational weeks, a healthy infant was born. Interim positron emission tomography (PET) performed after 2 and 4 cycles as well as at the end of chemotherapy showed complete metabolic response (Deauville 1). Brain MRI following treatment completion also showed complete remission of the pontine lesion.
      Figure
      FigureBrain MRI: Axial (A) and sagittal (B) T2-Fluid Attenuated Inversion Recovery (FLAIR) images reveal signal hyperintensity in the central pons (arrows). Axial T1-weighted image (C) shows a hypointense lesion without contrast enhancement in the central pons (arrow).  High signal intensity on diffusion-weighted imaging (DWI) (D) and low signal on apparent diffusion coefficient (ADC) map (E) are indicative of diffusion restriction. Complete lesion resolution is noticed on axial T2-FLAIR image 3 months later (F).
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