A 59-year-old man presented with vertigo and vomiting from another facility where he was treated with IVIG. Exam revealed normal vital signs, abulia, bradyphrenia, rotatory and vertical nystagmus, dysarthria, rigidity, ataxia, and weakness. Initial MRI showed a T2 hyperintensity in the midbrain and pons, without any enhancement. CSF revealed lymphocytic pleocytosis with atypical cells and normal protein. CT chest revealed L axillary lymphadenopathy and biopsy revealed nodular sclerosing Hodgkin’s lymphoma. There was notable improvement with plasmapheresis. He underwent 6 cycles of Doxorubicin, Bleomycin, Vinblasinte, and Dacarbazine. The abnormal MRI signal resolved and there was cerebellar atrophy noted at the fourteen and eighteen months follow up imaging.

The exact reason for these changes is unclear. It is possible that the hyperintensity on imaging was related to the neoplastic or paraneoplastic process and resolved upon treatment. Alternatively, the paraneoplastic process and exam findings pointed to cerebellar involvement which underwent an insult, and the initially hyperintense areas atrophied. The role of the specific treatment modalities cannot be confirmed, and further investigations are needed.