An Unusual Case of Central Nervous System Lymphoma Presenting With Ataxic Quadriparesis Showing ‘Wine glass’-Like Appearance

Abstract

The wine glass sign on brain magnetic resonance imaging (MRI) appears as symmetrical corticospinal tract hyperintensities on coronal sections in T2-weighted imaging. The differential diagnoses of the classical wine glass-like appearance include amyotrophic lateral scle-rosis and osmotic myelinolysis. 1,2 However, to the best of our knowledge, this sign has not been reported in other brain conditions, including tumors. Herein we describe an unusual case presenting with progressive ataxic quadriparesis over several months in a patient with a wine glass-like appearance in brain MRI without gadolinium enhancement. The patient was finally diagnosed as primary central nervous system (CNS) lymphoma. A 71-year-old female presented with recurrent falls accompanied by general weakness. Two months previously she had insidiously developed gait difficulty with postural instabil-ity that worsened progressively, resulting in her not being able to walk independently. A neurological examination revealed quadriparesis (4/5 muscle strength) of the motor system in all extremities, whereas sensory function showed no abnormalities. A mild-to-moderate de-gree of cerebellar ataxia was noted in all extremities. Her deep tendon reflexes were normo-active and her upper motor neuron signs were not remarkable. There were no symptoms of cognitive decline. Routine laboratory tests including of electrolytes produced normal findings. Serologic tests, including a test for vasculitis and an enzyme-linked immunosorbent assay for human immunodeficiency virus, were unremarkable. Brain MRI including axial fluid-attenuated inversion recovery (FLAIR) sequences showed slightly asymmetrical white-matter-dominant hyperintensities extending from the pons up to the corona radiata, al-though with some marginal lesions involving the thalamus and basal ganglia (Fig. 1A). Es-pecially notable was coronal T2-weighted imaging showing bilateral