Hodgkin lymphoma presenting as paraneoplastic cerebellar degeneration: A case report

A 49-year-old male presented with subacute onset of ataxia, dizziness, and dysarthria over a 4-week period. Laboratory workup and magnetic resonance imaging brain imaging were unremarkable, and no neurological etiology was identified. Anti-Tr antibodies were detected in serum and cerebrospinal fluid. A positron-emission tomography scan showed small nonspecific periaortic and aortocaval lymph nodes, which were not amenable for biopsy. He was treated with immunosuppressive treatment, and a CT scan showed resolution of the previous activity. A repeat positron-emission tomography scan 6 months after the original presentation showed reappearance with increased size and activity of the lymph nodes. An abdominal lymph node biopsy showed classical Hodgkin's lymphoma. The bone marrow biopsy was negative, placing him at Ann Arbor stage IIA. He was treated with two cycles of Adriamycin, Bleomycin, Vinblastine, and Dacarbazine followed by two cycles of Adriamycin, Brentuximab Vedotin, Vinblastine, and Dacarbazine due to a drop in diffusion capacity of the lungs for carbon monoxide from Bleomycin. He remains in remission from the lymphoma but with residual neurological symptoms. This case report suggests that patients with Hodgkin's and paraneoplastic neurological syndrome may demonstrate radiological improvement related to immunosuppressive treatment which can delay diagnosis and accurate treatment in patients with paraneoplastic cerebellar degeneration and underlying malignancy. The presence of anti-Tr antibody supports the diagnosis of Hodgkin lymphoma in the setting of paraneoplastic cerebellar symptoms.