Cutaneous lymphocytic vasculopathy in lymphoproliferative disorders--a paraneoplastic lymphocytic vasculitis of the skin

In this report the histopathology and the natural history of cutaneous lymphocytic vasculopathy (lymphocytic vasculitis) in patients with lymphoproliferative diseases, is described. Between January 1986 and June 1992, 116 patients with non-Hodgkin lymphomas (NHL) and chronic lymphocytic leukemias (CLL) were followed. Among them 3 patients with NHL, one with angioimmunoblastic lymphadenopathy/lymphoma and 7 with CLL developed cutaneous vasculitic changes during the course of their disease (incidence of 9.5%). All patients had advanced stage disease. Lymphomas were of B-cell origin and either low or intermediate grade. The median time between the diagnosis of NHL or CLL and the appearance of skin manifestations was 18 months. Recurrent vasculitic changes involving exclusively the skin, was characterized by a (maculo)papular rash, most commonly found in the upper and lower extremities. Pruritus of varying intensity was present in 82% of the patients. In the biopsy, all had perivascular and/or vessel wall lymphocytic infiltration of the dermis with occasional red cell extravasation. Immunohistochemical staining revealed that these infiltrates were mainly composed of T-lymphocytes. We conclude, that cutaneous lymphocytic vasculopathy is a relatively common paraneoplastic skin manifestation in patients with lymphoproliferative diseases and histologically is characterized as lymphocytic vasculitis with (peri)vascular infiltration by non-malignant T lymphocytes.

Epstein-Barr virus-associated non-Hodgkin's lymphoma in HIV-infected patients

Epstein-Barr virus (EBV) has been implicated in the pathogenesis of many lymphoproliferations arising in diverse settings, including HIV-infection. The precise roles of EBV may differ between these settings. For example, both the frequencies of EBV-association and the specific c-MYC translocations differ between sporadic and African Burkitt's lymphoma. Similarly, the frequencies of EBV-association in HIV-infected patients differs between anatomical sites, types of NHL, and geographic locations. HIV-related NHL have genetic alterations similar to NHL arising in the general population, and have less in common with the lymphoproliferations which arise in the setting of transplantation. However, the patterns of latent EBV transcription in systemic HIV-related NHL is unique among NHL, suggesting that EBV may contribute differently to their pathogenesis.

Small intestinal perforation due to cytomegalovirus infection in patients with non-Hodgkin's lymphoma

We describe two patients with non-Hodgkin's lymphoma (NHL) who suffered cytomegalovirus (CMV)-related small intestinal perforations during the course of chemotherapy. Surgical specimens from both patients revealed histologic evidence of occlusive vasculitis and tissue destruction caused by CMV-affected cells in the submucosa and muscular walls, that may have played an important role in the pathogenesis of these perforations. Although such intestinal perforations are rare complications in NHL patients, CMV infection should be recognized as a primary etiological factor in acute abdominal crises when treating NHL patients with pharmaceutical agents including steroids. Emergency surgery and the anti-CMV agent, ganciclovir, would improve the prognoses of such patients.

Reversal of 'refractory septic shock' by infusion of amrinone and angiotensin II in an anthracycline-treated patient

A 53-year-old granulocytopenic woman with malignant lymphoma treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy, including doxorubicin (Adriamycin) and autologues bone marrow transplantation, presented in the clinical state of "refractory septic shock" caused by Escherichia coli. Despite inotropic treatment with dopamine, dobutamine, and norepinephrine infusion, the patient's condition did not improve, but during treatment with amrinone and angiotensin II infusion, the septic shock was reversed. The patient was monitored with a pulmonary artery catheter and underwent repeated echocardiographic examinations. Antibiotic treatment with thienamycin and floxacillin was given. The initial reduction in cardiac performance in this patient may be explained by a state of true down-regulation of the myocardial beta-receptors. Apparently these beta-receptors were bypassed via the enzymatic action of amrinone upon cyclic monoadenosine phosphate. This is, to our knowledge, the first doxorubicin-treated patient with septic shock refractory to conventional vasopressor therapy whose condition reversed by inotropic treatment with amrinone and angiotensin II. This treatment may prove to be an alternative choice for patients developing "refractory septic shock" unresponsive to treatment with norepinephrine, dobutamine, and dopamine.

Mantle cell lymphoma with the features of mucosa-associated lymphoid tissue (MALT) lymphoma in an HTLV-I-seropositive patient

A case of small lymphocytic B-cell lymphoma with seropositivity for human T-cell leukemia virus type I (HTLV-I), whose clinical features were closely related to those of mucosa-associated lymphoid tissue (MALT) lymphoma, is presented. The neoplastic cells of the lymph node were immunologically positive for CD5, in addition to several B-cell markers, but negative for CD10, and cytogenetically carried a t(11;14)(q13;q32). These findings were fully consistent with so-called mantle cell lymphoma (MCL). In addition to the lymph nodes and bone marrow, multiple extranodal sites including lacrimal and salivary glands, lung and stomach (where MALT is present) were occupied by lymphoma cells. These extranodal lesions were immunologically identical to the lymph nodes (CD5(+), CD10(-)), but histologically showed lymphoepithelial lesions (LEL) characteristic of MALT lymphoma. These findings suggest a possible relationship between MCL and MALT lymphoma, and the neoplastic cells are thought to originate from the CD5-positive B cells, which are present near the areas across the mantle and marginal zones. Furthermore, HTLV-I-infection, which appears to create an immunodeficient state or modulate the B-cell response, is thought to play a role in B-cell lymphomagenesis.

Primary lymphomatous effusions in AIDS: a morphological, immunophenotypic, and molecular study

Lymphomas were documented in pleural effusions or ascites in 18 human immunodeficiency virus-positive (HIV+) patients. Eleven of 12 with clinical data had acquired immunodeficiency syndrome before the diagnosis of lymphoma. In 13 of 15 with data available, a body cavity was the site of initial presentation of lymphoma. Cytological subtypes were large cell immunoblastic, n = 7; large cell anaplastic, n = 6; and large cell NOS, n = 5. The high incidence of anaplastic large cell lymphoma and the conspicuous absence of Burkitt's lymphoma differ strikingly from HIV-associated lymphomas generally. Immunophenotypically, two cases were B-cell (CD19/20+, sIg+, CD/5-), one was T-cell (CD3+, CD5+, CD4+, CD8-, CD19/20-, sIg-), and 15 were null (CD45+, HLA-DR+ CD19/20-, sIg-, CD3/5-). This 83% incidence of null immunophenotype contrasts sharply with a 9% incidence among 35 tissue-based lymphomas in HIV+ patients that were similarly studied and a 0% null immunophenotype among 11 lymphomatous effusions in patients without HIV risk factors. Seven of the 18 HIV-associated lymphomas expressed CD30. Four of five cases with null immunophenotype showed Ig heavy-chain gene rearrangement, two had clonal Epstein-Barr virus integration, and none had MYC protooncogene rearrangement. These cases belong to a subgroup of high-grade HIV-associated lymphomas that occur in the setting of profound immunosuppression in which immunoblastic morphology predominates and MYC rearrangement is encountered only infrequently.

Doppler echocardiographic diagnosis and follow-up of acquired pulmonary stenosis due to external cardiac compression

Mediastinal tumors that cause hemodynamic disturbances by compressing the heart are extremely rare. We report the case of a 19-year-old woman who presented right ventricular outflow tract obstruction due to a non-Hodgkin lymphoma. The diagnosis of this complication and its response to chemotherapy can be accurately assessed by transthoracic echocardiography and Doppler.

Atypical palatal ulceration

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Chylothorax in non-Hodgkin's lymphoma managed by mediastinal radiotherapy

Chylothorax is a rare complication of both Hodgkin's and non-Hodgkin's lymphoma (NHL). We describe a patient with a diagnosis of low grade NHL who had a persistent chylothorax unresponsive to chemotherapy, who had been diagnosed with low grade NHL. The condition rapidly resolved following mediastinal radiotherapy and did not recur despite the subsequent relapse of the NHL.

[Pancoast's syndrome secondary to non-Hodgkin's lymphoma]

Pancoast's syndrome is usually found coincident with bronchogenic carcinoma. We describe a case of non-Hodgkin's lymphoma presenting with Pancoast's syndrome in a patient with a history of thoracoplasty.

High IL-6 serum levels are associated with septic shock and mortality in septic patients with severe leukopenia due to hematological malignancies

The serum levels of immunoreactive interleukin-6 (IL-6) and tumor necrosis factor (TNF) were analyzed in 14 leukopenic patients with documented sepsis, at 60 min (T0), 24 h (T1), and one week (T3) after the onset of sepsis syndrome. Sera from 10 leukopenic patients without sepsis (controls) were also tested. All septic patients had high IL-6 levels at T0. These levels persisted only in the seven patients who died of septic shock, presenting a 30-fold increase (p<0.001) as compared to the survivors and the controls. At T3, 7 survivors had recovered from sepsis and showed low IL-6 serum levels. The TNF serum concentration always <30 pg/ml in both the subjects and in the controls. The C-reactive protein (CRP) and clinical parameters appeared to be less specifically associated with shock and mortality than IL-6.

Fast spin-echo MR imaging of non-Hodgkin lymphoma arising from chronic tuberculous empyema

Non-Hodgkin lymphoma (NHL) rarely arises from tuberculous empyema. We report a case in which magnetic resonance (MR) imaging was useful in separating the lymphoma from the chronic empyema.

Gastrocolic fistula secondary to primary gastric lymphoma

Gastrocolic fistula in primary non-Hodgkin's lymphoma (NHL) of the stomach is rare; in a review of the literature we found only four cases, all in association with disseminated (stage IV) disease. We describe the first case of a gastrocolic fistula in a patient with stage IE lymphoma. The diagnosis was suggested by feculent vomiting, and the fistula was located using barium enema and CT scan. Therapy consisted of local resection followed by combination chemotherapy.

Real time monitoring in the control theory paradigm

Monitoring patients hospitalized in hemato-oncology departments to undergo clinical protocols of therapy is a complex task. The main difficulty arises in the follow-up of the oncology protocol and in the management of critical episodes of acute illness which frequently occur due to the high toxicity of the antimitotics used. This problem can be conceptualized within the control theory paradigm as the task of controlling a process whose state can deviate unacceptably from a normal range. Following the control theory analogy at the level of knowledge bases design, we have modeled the medical knowledge as control information to represent the medical actions, and state information is used as a feedback control to readjust the command.

[Rhinocerebral mucormycosis in a case of malignant lymphoma]

Mucormycosis, an uncommon opportunistic fungal infection, usually occurs in immunocompromised patients. It is rapidly progressive and almost always fatal. Patients with lymphoma are susceptible to pulmonary or disseminated mucormycosis, whereas rhinocerebral mucormycosis in such patients, as far as we know, is rarely reported. We present a patient with malignant lymphoma who exhibited such an acute rhinocerebral infection after chemotherapy which manifested initially as a stuffy nose and intractable headache. Then ptosis, proptosis, chemosis and multiple cranial nerve palsies appeared. Eschar was found in the nasal cavity. Direct KOH smear and tissue biopsy revealed mucormycotic infection. He survived because of early diagnosis and prompt treatment.

Infection due to Mycobacterium haemophilum identified by whole cell lipid analysis and nucleic acid sequencing

A patient with indolent, non-Hodgkin's lymphoma developed a pretibial soft tissue abscess caused by a fastidious mycobacterium. Because the organism could not be definitively identified by standard microbiologic testing, whole cell fatty acid analysis and 16S rDNA sequencing were performed. These procedures identified the organism as Mycobacterium haemophilum. We review the diagnostic considerations with regard to this pathogen.

[A case of Corynebacterium jeikeium septicemia]

We report a case of Corynebacterium jeikeium septicemia associated with malignant lymphoma. The patient is a 58-year-old male who was diagnosed as malignant lymphoma on August 1992. May 15, 1993, he was admitted to our hospital because of oliguria, abdominal flatulence and vomiting which developed a few days before admission. Anticancer regimen were started. In the middle of July, white blood cell (WBC) count dropped to 100/mm3 and body temperature rose to 39 degrees C. He was been treated with Ceftazidime and Piperacillin. C. jeikeium was recovered from blood culture. Antibiotics were switched to minocycline and vancomycin. He died of septic shock and pneumonia. Autopsy revealed the presence of the colonies of Rods. Which were morphologically compatible with C. jeikeium were observed in lung tissue and in the small pulmonary vessels.

Liver lesions in cryoglobulinaemia associated with gastric non-Hodgkin lymphoma: a case report

Liver lesions in cryoglobulinaemia, associated with gastric non-Hodgkin lymphoma, are described in a 67-year-old woman. Histological examination showed capillaropoiesis in some portal tracts with vessels containing amorphous, eosinophilic and PAS-positive material, which immunohistochemically was shown to contain IgM and k light-chains.

Intrapleural bleomycin in the treatment of chylothorax

Chylothorax is an accumulation of thoracic lymph or chyle in the pleural cavity. It is a rare condition and is usually caused by trauma or malignant disease. We present three cases with chylothorax due to malignant non-Hodgkin's lymphoma [high grade malignant (1 case) and low grade malignant (2 cases)] treated with pleurodesis with bleomycin and systemic chemotherapy (CHOP, CNOP, trofosfamide). Complete remissions (CR) were achieved in all three cases. Two patients had a recurrent chylothorax 3 and 12 months after initial treatment. They were treated with a second intrapleural installation of bleomycin and continuing systemic chemotherapy (CNOP, trofosfamide) and are still alive in CR with a follow-up period of 28 and 30 months respectively. One patient died of relapsing non-Hodgkin's lymphoma after 23 months of follow-up. There was no sign of recurrent chylothorax. We conclude that chylothorax caused by lymphoma can be satisfactorily controlled by pleurodesis with bleomycin combined with systemic chemotherapy. Immediate action is necessary to prevent great loss of lipids and proteins. The underlying malignancy must be controlled to achieve a good prognosis.

Bone marrow involvement in non-Hodgkin's lymphoma in Zimbabwe

Lymph node and bone marrow trephine biopsies of seventy two consecutive cases of non-Hodgkin's lymphoma occurring among black Zimbabweans were reviewed to determine bone marrow involvement. The bone marrow was involved in 23.6% of patients but the proportion of bone marrow positive cases was highest in low grade lymphomas, though these were the least common type of lymphoma encountered. Cells infiltrating the marrow showed high degree of concordance with corresponding lymph node histology. Low grade lymphomas (CLL excluded) had a predominantly diffuse pattern of marrow involvement while intermediate and high grade lymphomas had nearly equal proportions with diffuse and focal patterns. Bone-marrow involvement did not make a significant difference to the staging of non-Hodgkin's lymphoma as most cases not involving the marrow also presented with advanced disease. Mean age of patients was negatively correlated with histological grade but was not related to bone marrow involvement. Central nervous system involvement occurred mostly in the high grade lymphomas and was proportionately distributed between bone marrow positive and negative cases. 40% of non-Hodgkin's lymphoma were associated with HIV infection but HIV-associated lymphoma surprisingly very rarely infiltrated the bone marrow.

[Abdominal pain, weight loss, tarry stools]

A 65-year-old man had abdominal pain and night sweat for several weeks. He had lost weight and also reported black stools. Anemia of iron deficiency was found in laboratory tests. Further investigation revealed a stenosing process in the small intestine as source of bleeding. High grade non-Hodgkins' lymphoma was diagnosed histologically in the resected bowel segment and the mesenteric lymph nodes. Further staging did not reveal further manifestations of lymphoma. Polychemotherapy and subsequent irradiation were administered.