A 74-year-old lady presented to a district hospital with ataxia, a left sixth nerve palsy, and a sensorimotor neuropathy over a several month period. Baseline blood tests revealed a macrocytic anaemia, but were otherwise unremarkable. Tumour markers, autoimmune and initial screening of causes of macrocytosis were negative. In particular onconeuronal and glycolipid antibodies were also negative. MRI of the brain and spine were essentially normal. Cerebrospinal fluid (CSF) examination revealed a raised protein level with type 6 oligoclonal bands. Remaining CSF analysis including microbiology and cytology was normal. Nerve conduction and electromyogram studies confirmed presence of a severe motor and sensory axonal neuropathy. A course of intravenous immunoglobulin was administered with no improvement from her functionally bed bound status. She then developed marked hypercalcaemia. Computed tomography (CT) of the chest, abdomen and pelvis revealed no malignancy. The clinical course was complicated by severe septicaemia. Her anaemia worsened and haemolysis screening confirmed a cold autoimmune haemolytic anaemia. Haematological malignancy was strongly suspected and subsequent trephine biopsy revealed infiltration by diffuse large B cell lymphoma. Thus, we report a presentation of B-cell lymphoma with paraneoplastic vs neoplastic related subacute neuropathy.
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