Case report 674: Well-differentiated lymphocytic lymphoma with skeletal involvement

We report the case of a man with generalized osteosclerosis secondary to well-differentiated lymphocytic lymphoma. This finding is considered to be exceptional in this type of lymphoma, especially when other organs were not found to be involved. A year after the diagnosis was established the patient appeared to be in relatively good health. The radiological pattern showed no change from the original studies, nor was there any evidence of neoplastic involvement in any other location.

Hodgkin's disease in patients with antibodies to human immunodeficiency virus. A study of 22 patients

The experience of 22 Hodgkin's disease (HD) patients with human immunodeficiency virus type I (HIV) antibodies, collected from a cooperative study of six hospitals during 1984-1989 is presented. Young men (average age, 27.6 years) with a high incidence of intravenous drug abuse (86%) were found. The status of the HIV infection at diagnosis of HD was: four patients, acquired immune deficiency syndrome (AIDS); eight patients, persistent generalized lymphadenopathy (PGL); and ten patients, asymptomatic. The natural history of HD was unusual, with a high incidence of B symptoms (81%), advanced Stages III to IV (90%), bone marrow invasion (50%), cytopenias before treatment (45%), opportunistic infections (68%), and aggressive histologies. A decreased response to chemotherapy with poor marrow tolerance and a significant decrease in survival, 18 months, was observed. The AIDS and cytopenias pretreatment were associated with a shorter statistically significant survival, which defines the importance of immunodeficiency in HD prognosis. Complete remission after treatment was a factor that contributed to a longer statistically significant survival. The PGL or asymptomatic patients survived longer but also had a poor course, and five of them had AIDS criteria during evolution. A high incidence of HD in relation to non-Hodgkin's lymphoma (NHL) in patients with HIV infection in the six cooperating hospitals was found. Criteria for considering HD as an AIDS-associated lymphoproliferative disease in our environment are discussed.

[Intraparenchymal non-neoplastic residual masses after treatment of large-cell non-Hodgkin's lymphoma with intensive chemotherapy]

We report two patients with large-cell non-Hodgkin's lymphomas who were treated with intensive chemotherapy (MACOP-B), and in whom large isolated intraparenchymal masses (splenic in one case, renal in the other) were found with computed tomography after clinical remission. It was found at surgery that both masses were constituted by acellular necrotic material, without tumoral infiltration and limited by fibrous tissue. The finding of these residual masses in patients in remission raises problems of approach, as they may be nontumoral and not require new therapy. At present, until new radiological or biochemical markers are available, a judicious clinical attitude should be taken, with radiological control of the evolution of the masses and reserving surgery only for those cases with progression, diagnostic doubts, or patient's decision to know his real status.

[Neutropenic enterocolitis during treatment of lymphoproliferative neoplasms]

In a series of 320 patients with lymphoid neoplasms treated with polychemotherapy, three patients with non-Hodgkin's lymphoma and one with myeloma were diagnosed as having neutropenic enterocolitis (NEC). All patients were adult, all had received multiple chemotherapeutic drugs and, during neutropenia, they had clinically presented with fever and abdominal pain, generally in the right lower quadrant. The diagnosis was clinical in all cases, and the imaging techniques provided only the suspicion of retro-cecal abscess in one of them. Two patients were operated on because of the development of features of peritoneal involvement, another because of septic shock and another because of retro-cecal abscess. Surgery and pathological study confirmed the diagnosis. The fundamental findings were ileocecal wall edema, mucosa ulceration, local necrosis, hemorrhage and thrombosis, and clusters of bacterial colonies without evidence of granulocytic or tumoral infiltration. NEC can develop with varying types of morphological involvement resulting in a highly variable clinical severity spectrum ranging from nonspecific abdominal symptoms to acute abdomen. Thus, diagnosis is very difficult and is only possible with a high suspicion index. It should rely on clinical data, which are unique, to assess the evolution and to indicate medical or surgical therapy. These therapeutic modalities should be individualized in each patient. All physicians treating neutropenic patients should be familiar with this condition and consider it in the differential diagnosis of abdominal pain.

[Lymphoma of the rectum associated with lymphoid nodular hyperplasia in a common variable immunodeficiency]

A patient with common variable immunodeficiency developed lymphoid nodular hyperplasia and, subsequently, a follicular non-Hodgkin lymphoma with excellent response to chemotherapy. The patient remained in remission after 4 years. The very unusual type of this lymphoma and its localization are discussed, and the possible relations between these different conditions as a single spectrum of B lymphocyte are analyzed.

[Multicentric abdominal angiofollicular hyperplasia: a clinical variant with exclusive involvement of the liver and abdominal lymph nodes]

Three patients with a non-malignant lymphoproliferative disease involving liver and abdominal lymph nodes, without peripheral lymphadenopathy, are presented. They had systemic symptoms, fever and/or arthralgia, a biochemical pattern of liver obstruction and signs of B-cell immune hyperactivity (hypergammaglobulinaemia and different autoantibodies). Abdominal lymph node enlargement was found on laparotomy; the lymph node histologic pattern was that of angiofollicular hyperplasia (AFH), malignant lymphoma being discarded. Several stages of involvement were present in all cases, made up of small lymphocytes, plasma cells, and centrofollicular cells forming portal nodules with cholangiole infiltrates in one case which gave rise to a lymphoepithelial lesion. Steroid therapy was effective in all cases, but the symptoms and the liver obstruction relapsed in two patients after steroid suppression. Persistent functional anomalies of B and T lymphocytes were present in all cases. No evidence of viral disease was seen. These patients form a clinicopathological variant of multicentric AFH on whom malignant lymphoma could be excluded only by the histological study of abdominal lymph nodes. The persistence of lymphocytosis (although polyclonal and lacking cytogenetic alterations) may suggest the possible evolution into true and malignant lymphoma in any case.

[Ki-1 non-Hodgkin's lymphoma. A multihospital study of 21 cases]

The Ki-1 monoclonal antibody recognizes a specific membrane antigen of activated lymphoid cells and stains large-cell non Hodgkin's lymphomas and Hodgkin's disease. Thus, it is widely used in the diagnosis of anaplastic lymphomas. Morphologically, the Ki-1 monoclonal non Hodgkin's lymphoma are diffuse of multifocal either classical or cell anaplastic type. The clinical behaviour is similar to the rest of the high grade lymphomas, disseminated at diagnosis but may reach remission after aggressive chemotherapy. The immunophenotype showed T, B or null nature of the latter. The clinical and pathological results of our study carried out in a group of 21 cases ki-1 positive lymphomas is herewith reported.

Peripheral T-cell lymphoma. A clinical, histologic, and immunologic study of five cases

The authors describe five white patients with peripheral T-cell lymphoma. Four patients were older than 65 years. All cases presented with a short clinical course and advanced stage at the time of diagnosis. Clinical manifestations included asthenia, weight loss, peripheral and abdominal lymphadenopathy. One case showed tonsillar involvement and subcutaneous lymph node enlargement; hepatomegaly was present in four cases, two of them with splenomegaly. Only one case presented peripheral lymphocytosis and antibodies to human T-leukemia virus. Although three cases were classified as diffuse mixed lymphomas and two as poorly differentiated lymphocytic lymphomas, there were some common characteristics: diffuse infiltration by different proportions of small lymphoid cells and large immunoblasts, some of them multinucleated and similar to Reed-Sternberg cells; accumulation of histiocytes, plasmacytosis, eosinophilia, venular proliferation and compartmentalization were also found. Bone marrow infiltration was observed in two patients. Results of monoclonal markers showed four cases to be OKT4+ and the other OKT8+. The morphologic and immunologic characteristics of these patients were typical and similar to those reported from other geographical areas.

Multiple myeloma with crystalline inclusions in most hemopoietic cells

Intracytoplasmic inclusions were observed at light and electron microscopy in the cells of most of the hemopoietic series, including erythroblasts, in a case of multiple myeloma IgG kappa. The inclusions were of crystalline nature, surrounded by smooth membrane. An indirect immunoperoxidase method on thick sections confirmed their immunoglobulin G kappa nature. The fact that crystals were observed in various hemopoietic series suggests that, except for the plasma cells, their presence is more likely due to phagocytosis than to synthesis and, therefore, that they are not a clone marker.

Transection of the spermatic vessels (Bevan's technique): an experimental study

Intracanalicular or intra-abdominal undescended testicles often present a difficult surgical problem, due to a vascular pedicle shortening that prohibits scrotal placement with a 1 stage orchiopexy. The division of spermatic vessels to properly place the testis in the scrotum solves the problem of the shortening of the vessels, but raises the question of whether the endocrine function and the potential for fertility are preserved. In the present study transection of spermatic vessels before arterial branch-off was done intra-abdominally in rats. Angiographic, patho-anatomic and hormonal evaluations have been made. Revascularization of the testicular artery through the vasal artery has occurred in all cases. The anastomotic circuit, however, does not always have the same functional value. The spermatogenic alterations suggest that fertility can be impaired in a significant percentage of cases. Spermatogenesis was quantified taking into account the mean tubular diameter and the situation of seminiferous epithelium, expressed as the percentage of tubules containing well-developed spermatogenesis. Plasma testosterone levels are in a low range. However, Leydig cell functional response to human chorionic gonadotropin stimulation is maintained in every case and so are plasma and pituitary luteinizing hormone levels, suggesting that plasma testosterone levels are high enough to maintain an adequate hormonal activity.

Mesangial proliferative glomerulonephritis with unusual intramembranous granular dense deposits

We have studied two patients with histories of upper respiratory tract infection. Hematuria and proteinuria were the presenting renal symptoms in one patients and an acute nephritic syndrome in the other. Serological findings disclosed depression of total hemolytic complement activity with low levels of C3 and the presence of C3Nef activity. Light microscopy showed diffuse mesangial cell proliferation. By immunofluorescence, diffuse deposits of C3 were found in the glomeruli. Ultrastructural studies revealed segmental thickening of the glomerular basement membrane due to the deposition of granular electron-dense deposits in a laminar pattern. We suggest that our cases may represent a variant of hypocomplementemic glomerulonephritis or perhaps the early stages of dense deposit disease.

Mesangial deposits of IgM in patients with the nephrotic syndrome

Kidney biopsies from fourteen patients with the nephrotic syndrome were studied by light, immunofluorescence and electron microscopy. Morphologically, all cases showed moderate diffuse mesangial cell proliferation. In all cases, immunofluorescent microscopy demonstrated diffuse and generalized deposits of IgM as the sole or predominant immunoglobulin. Electron microscopic examination showed electron dense deposits localized in the mesangium in seven cases. One nephrotic patient experienced spontaneous remission and eight others were steroid responsive. Only one of the five steroid resistant patients treated with chlorambucil showed clinical remission. Five steroid responsive patients relapsed. At present, four patients are healthy, having not relapsed for the past two years. Although deposits of IgM may be related to the renal pathology in cases of the nephrotic syndrome, immunofluorescence findings do not seem to be sufficiently consistent or characteristic to justify a possible subclassification of the idiopathic nephrotic syndrome.