Case Report: An interesting case of vision and hearing loss revealing CNS recurrence in Philadelphia-positive acute lymphoblastic leukemia

BackgroundCentral nervous system (CNS) relapse in acute lymphoblastic leukemia (ALL) may occur despite systemic remission and can present with isolated neuro-ophthalmologic symptoms. Early diagnosis may be challenging as the initial neuroimaging and ophthalmologic evaluation can be non-diagnostic.Case presentation/discussionWe report on a 57-year-old man with Philadelphia chromosome-positive (Ph+) B-cell ALL in remission on dasatinib maintenance therapy who presented with acute vision and hearing loss. The initial evaluation, including magnetic resonance imaging (MRI) and ophthalmologic examination, did not reveal a definitive etiology, and drug-induced toxicity was initially considered. However, cerebrospinal fluid (CSF) analysis demonstrated lymphoblasts, establishing the diagnosis of CNS relapse. Repeat imaging later revealed leptomeningeal and optic nerve sheath enhancement consistent with disease progression. The patient was treated with intrathecal chemotherapy, with subsequent clearance of CSF blasts.ConclusionThis case highlights delayed recognition of CNS relapse due to initial diagnostic anchoring and underscores the limitations of early imaging in detecting CNS involvement. CSF analysis remains the most sensitive diagnostic modality and should be pursued early in patients with ALL who present with unexplained visual or neurologic symptoms.