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A 67-year-old male was transferred to our hospital with diplopia, decreased deep tendon reflex and ataxia. He had been suspected Fisher syndrome because of previous upper respiratory tract infection. A cerebrospinal fluid examination showed marked hypoglycorrhachia, pleocytosis and elevated protein, and cytological examination suggested malignant lymphoma. Abdominal computed tomography revealed a left adrenal mass. A biopsy of the left adrenal mass revealed diffuse large B-cell lymphoma. He was treated with a combination of R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, oncovin and prednisolone) and intrathecal administration of methotrexate, cytarabine and prednisolone. Neurological symptoms were gradually improved. Malignancy should be considered in addition to bacterial, fungal or tuberculous meningitis in a case with marked hypoglycorrhachia.

We measured rituximab concentrations in the cerebrospinal fluid (CSF) in 2 patients with diffuse large B-cell lymphoma in whom central nervous system (CNS) invasion had developed. They received rituximab intravenously following irradiation therapy (patient no.1) or along with chemotherapy (patient no.2). The rituximab concentrations in the CSF were considered to be very low (0.2-0.6 microg/ml), and could not be increased significantly by serial intravenous administrations of rituximab. The lymphoma relapsed in patient no.1, and the combined therapy was not effective in patient no.2. An alternative approach such as intrathecal administration of rituximab could be anticipated as a new therapeutic strategy for CNS lymphoma.