Differential Diagnosis for 88-year-old with CLL presenting with ataxia, dizziness, confusion, hallucinations, and abnormal imaging findings
- Single most likely diagnosis:
- Richter's transformation: This is a transformation of chronic lymphocytic leukemia (CLL) into a more aggressive lymphoma, such as diffuse large B-cell lymphoma. The symptoms and imaging findings, including hypert2 mesiotemporal and gyral thickening, could be consistent with central nervous system (CNS) involvement by lymphoma. The acute lump on the neck could represent lymphadenopathy.
- Other Likely diagnoses:
- Progressive multifocal leukoencephalopathy (PML): This is a rare and often fatal viral disease caused by the JC virus that affects the CNS and can cause ataxia, confusion, and hallucinations. It is more common in immunocompromised patients, such as those with CLL.
- CNS lymphoma: This is a type of cancer that originates in the CNS and can cause symptoms similar to those presented. The abnormal imaging findings and negative CSF do not rule out this diagnosis.
- Infections: Such as meningitis or encephalitis, which can cause similar symptoms and should be considered in an immunocompromised patient.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.):
- Subdural hematoma or other intracranial hemorrhage: This could cause sudden onset of symptoms, including confusion, ataxia, and hallucinations. Imaging studies, such as CT or MRI, are essential to rule out this diagnosis.
- Status epilepticus: This is a life-threatening condition that can cause confusion, ataxia, and hallucinations. An EEG would be necessary to diagnose this condition.
- Meningitis or encephalitis due to a specific pathogen: Such as listeria or cryptococcus, which can cause severe and potentially life-threatening illness in immunocompromised patients.
- Rare diagnoses:
- Paraneoplastic syndromes: These are rare disorders that are triggered by an abnormal immune response to a cancer, such as CLL. They can cause a variety of neurological symptoms, including ataxia, confusion, and hallucinations.
- Primary CNS vasculitis: This is a rare condition that causes inflammation of the blood vessels in the CNS and can cause a variety of neurological symptoms.
- Hashimoto's encephalopathy: This is a rare condition that causes inflammation of the brain and can cause symptoms similar to those presented.