Teaching NeuroImage: Thickened and Enhanced Cauda Equina as a Manifestation of Acute Lymphoblastic Leukemia Relapse

A 20-year-old man with a history of B-cell acute lymphoblastic leukemia (ALL) in remission reported a 2-week history of bilateral lower limb weakness. Electrophysiologic examination showed prolonged latency of F-wave of bilateral tibial nerves. The CSF opening pressure was increased (>30 cm/H20), with elevated protein level (1683 mg/L, RI 150–400 mg/L), decreased glucose concentration (5.94 mg/dL, RI 50.4–80.64 mg/dL), and pleocytosis (854/mm3, RI < 10/mm3) in CSF. Flow cytometry assays for detecting minimal residual disease in CSF disclosed numerous lymphoblasts (CD45+, CD19+, CD34+, CD10+, CD38±, and CD20), and lumbosacral MRI showed thickened and homogeneously enhanced cauda equina, which were consistent with nervous system relapse of B-cell ALL (Figure).1 Cauda equina involvement as a manifestation of ALL relapse is rare, and lumbosacral MRI markedly improved diagnosis.

Figure Lumbosacral MRI

T2-weighted axial (A.a) and sagittal (A.b) lumbosacral MRI revealed thickened cauda equina. T1-weighted, postcontrast axial (B.a) and sagittal (B.b) lumbosacral MRI demonstrated thickened and homogeneously enhanced cauda equina.

Study Funding

This work was supported by the Innovation Research Team Project of Natural Science Foundation of Hainan (2018CXTD348).


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  • Received November 29, 2021.
  • Accepted in final form February 25, 2022.

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