Optic disk edema in a patient with non-Hodgkin's lymphoma: is there a metastasis to the brain?

The manifestation of bilateral disk swelling raises the suspicion of papilledema and mandates that an etiology for increased intracranial pressure be discovered. This case report will present the manifestations and treatment of non-Hodgkin's lymphoma and review the differential diagnoses of bilateral disk edema.

A 51-year-old black man manifested symptoms of dizziness and intermittent loss of vision in the left eye for one week. Dilated funduscopy revealed early left optic disk edema; edema of the right optic nerve head was questionable. The patient had pulmonary nodules noted on a recent chest x-ray that were thought to be cancerous; this raised the suspicion of a metastasis to the brain or orbit. The patient did not return until about 10 weeks later, at which time he presented with a history significant for newly-diagnosed intermediate-grade non-Hodgkin's lymphoma. He had begun chemotherapy one month before the second examination at our clinic; methotrexate therapy for CNS metastasis had been provided at the time of the spinal taps. At the second visit, there was marked progression of the swelling of the left optic disk and mild swelling of the right disk. At the third visit, six weeks later, the disk edema had improved remarkably. The patient's disk swelling resolved completely by the end of his six months of chemotherapy.

This is a unique presentation of a patient at high risk for brain metastasis, in which laboratory and radiologic studies failed to provide adequate supportive evidence for the conclusions drawn from clinic observations. Bilateral disk edema in a patient with a history of non-Hodgkin's lymphoma is strongly suggestive of a metastatic tumor to the brain causing increased intracranial pressure.