Supplementary Material for: Intravascular Large B-cell Lymphoma Presenting as Migraine with Aura: Case Report

Introduction Intravascular large B-cell lymphoma is a rare, fatal, aggressive lymphoma which is characterized by proliferation of clonal lymphocytes within the lumen of small, medium, and large vessels. Diagnosis is challenging given non-specific initial presentation. Incidence is less than one case per 1 million per year worldwide. Case report We report a case of intravascular large B-cell lymphoma in a 62-year-old female who presented to clinic with symptoms of migraine with aura. MRI brain showed T2 hyperintensities in the splenium of the corpus callosum, right frontal and bilateral parietal lobes which progressed on repeat imaging. Laboratory studies only showed mild elevation of Alanine aminotransferase (ALT) to 75 (8-35 U/L). Computer tomography of chest abdomen pelvis showed splenomegaly but did not show lymphadenopathy or masses. She underwent brain biopsy and was found to have intravascular large B-cell lymphoma and was transferred to specialist oncological center to be started on R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy. She passed away 7 months after the initial outpatient visit. Conclusion The initial presentation of migraine with aura was not previously described. Non-specific initial laboratory studies, pre-existing Waldenstrom’s macroglobulinemia which explained splenomegaly, absence of masses in the chest, abdomen, and pelvis, absence of lymphadenopathy, and MRI imaging mimicking multiple sclerosis made the diagnostic process exceedingly difficult. We demonstrate another presentation of this rare and fatal disease and hope that the reader will consider this differential diagnostic possibility when evaluating patients with rapidly worsening neurological symptoms.