Missed Diagnosis of Non-Hodgkin`s Lymphoma in an Elderly Patient Presenting with Spinal Cord Compression

Spinal Cord Compression (SCC) occurring in an adult with Neurofibromatosis Type-1 (NF-1); is most readily attributed to a spinal neurofibroma or a metastasizing neurofibrosarcoma. Rare causes including Non-Hodgkin’s Lymphoma (NHL) are seldom considered in the list of differentials. We report a 65-year-old man who had clinical features of neurofibromatosis type-1 since childhood. He first presented to our neurosurgical service two months after he developed weakness and anesthesia in lower extremities, incontinence of urine and faeces and progressive weight loss. He had developed a large painless midline mass in the lowback two years earlier. Examination revealed multiple cafe-au-lait macules, axillary frecklings, a subcutaneous nodule and a firm plexiform lumbosacral mass. A dorso-lumbar CT scan showed a large lobulated soft tissue mass over the lumbosacral segment involving the gluteal and the paraspinal muscles, with intraspinal extension causing L3-5 vertebral collapse and epidural compression. Lytic lesions were also apparent in the iliac bones and L3-5 vertebral bodies. A decompressive laminectomy and biopsy was done and subsequent histological findings were consistent with the diagnosis of mixed cell non-Hodgkin’s lymphoma. He was commenced on steroid therapy but he refused planned radiotherapy and cytotoxic chemotherapy opting for a voluntary discharge. He died three weeks afterward. This case illustrates the grave consequence that accompanies a belated diagnosis of a treatable condition and that cord compression is not always due to NF1 related lesions in patients with NF-1. The significance of histological verification of mass lesions of NF-1 in avoiding missed diagnosis cannot be overemphasized.