Angio-immunoblastic lymphadenopathy. Diagnosis and clinical course

Fatal lymphoma after transplantation of cultured thymus in children with combined immunodeficiency disease

A fatal, widespread, polyclonal, B-cell immunoblastic lymphoproliferative disorder developed in three children with combined immunodeficiency shortly after intra-abdominal transplantation of cultured thymus epithelium for immunoreconstitution. All three had surface immunoglobulin-bearing cells (15 to 20 per cent) in the peripheral blood before transplantation and polyclonally elevated immunoglobulins afterward. Abnormal immunoregulation was demonstrated by a lack of concanavalin A-induced suppressor-cell activity in mixed leukocyte culture in all three patients before transplantation and in two afterward. We suggest that the transplant acted as a promoter through immunostimulation or production of promoter factors, and that excessive polyclonal B-cell proliferation resulted because of inadequate immunoregulatory mechanisms. Although this complication occurred in only three of 30 patients with various forms of immunodeficiency treated with cultured thymus, these cases illustrate a potential problem in immunoreconstitution of combined immunodeficiency disorders.

Cutaneous manifestations of angioimmunoblastic lymphadenopathy

Angioimmunoblastic lymphadenopathy (AIL) is an uncommon immunoproliferative disorder with a presentation similar to malignant lymphoma but with a benign histopathologic picture. We report a case of a 49-year-old woman with AIL who manifested a pruritic maculopapular eruption as her presenting complaint and whose disease pursued an aggressive clinical course. Forty-four percent of patients with AIL experience a nonspecific dermatitis that in general is maculopapular and precedes other clinical symptoms by at least several weeks. AIL should be included in the differential diagnosis of any maculopapular eruption of unknown etiology accompanied by lymphadenopathy.

Rubella virus antigen in lymphocytes of patients with angioimmunoblastic lymphadenopathy (AIL)

Lymph node sections from 14 patients with angioimmunoblastic lymphadenopathy (AIL) were incubated with fluorescein-labeled specific antiserum against rubella virus antigen. In lymphoid cells from 11 patients intracytoplasmic rubella antigen was demonstrated. The results support the idea of a persistent virus infection in AIL.

Virus-associated hemophagocytic syndrome: a benign histiocytic proliferation distinct from malignant histiocytosis

Nineteen patients whose bone marrow smears showed histiocytic hyperplasia with prominent hemophagocytosis were found to have a clinicopathologic syndrome associated with active viral infection. High fever, constitutional symptoms, liver function, and coagulation abnormalities and peripheral blood cytopenias were characteristic findings. Hepatosplenomegaly, lymphadenopathy, bilateral pulmonary infiltrates, and skin rash were often present. Fourteen of the patients were immunosuppressed. Active infection by herpes group viruses was documented in 14 patients and by adenovirus in 1. The bone marrow of most patients also showed decreased granulopoiesis and erythropoiesis with normal to increased numbers of megakaryocytes. Treatment generally consisted of supportive therapy and withdrawal of immunosuppressive drugs. Thirteen patients recovered. Lymph node biopsy and autopsy material showed generalized histiocytic hyperplasia with hemophagocytosis. The relationship of this disorder to familial hemophagocytic reticulosis, familial erythrophagocytic lymphohistiocytosis, histiocytic medullary reticulosis, and malignant histiocytosis is discussed. Immunosuppressive and cytotoxic therapy may be contraindicated in the treatment of this virus-associated syndrome.

Angioimmunoblastic lymphadenopathy with dysproteinemia. A pathogenetic link between lymphoid proliferation and malignant lymphoma

Two patients with angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) were studied. Both patients had marked increases in all three major immunoglobulin classes, and both lacked suppressor cell activity in vitro. These findings are consistent with the theory that AILD is a defectively regulated immune response to an unidentified antigen(s) and could provide clues to the pathogenesis of other lymphoproliferative disorders as well.

Immunoblastic sarcoma with features of Sjögren's syndrome and systemic lupus erythematosus in a patient with immunoblastic lymphadenopathy

A patient with immunoblastic lymphadenopathy and features of Sjögren's syndrome and systemic lupus erythematosus is presented. Clinical features included generalized lymphadenopathy, rash, alopecia, and synovitis, with associated laboratory abnormalities of a positive antinuclear factor and double-stranded DNA antibodies, positive lupus band test, and hemolytic anemia. Symptoms of Sjögren's syndrome included dry eyes and mouth and swollen parotid gland; biopsy results of the accessory salivary glands were positive. At autopsy immunoblastic sarcoma was found that involved the myocardium, which stained for both kappa and lambda light chains by immunoperoxidase techniques.

Malignant lymphoma with a high content of epithelioid histiocytes

A series of 12 patients with a rare malignant lymphoma containing numerous epithelioid histiocytes (MLEH), originally believed to be an atypical variant of Hodgkin's disease, is described. Clinicopathological studies suggest MLEH is a distinct entity among the non-Hodgkin's lymphomas which is generally resistant to therapy and has an unfavourable prognosis. Differentiation of the disease from angioimmunoblastic lymphadenopathy and Hodgkin's disease is discussed. In the necropsy case MLEH had transformed into a malignant lymphoma of histiocytic type.

Vasculitis and Sjögren's syndrome with IgA-IgG cryoglobulinemia terminating in immunoblastic sarcoma

Generalized lymphadenopathy and other manifestations of Sjögren's syndrome developed in a 68 year old woman with a long history of systemic vasculitis and arthralgia. An unusual immunologic feature was hypogammaglobulinemia and immunoglobulin A (IgA) monoclonal immunoglobulinemia with mixed IgA-IgG cryoglobulin. At autopsy, the histopathologic findings were compatible with immunoblastic sarcoma. The monoclonal IgA protein, found in serum, pleural and pericardial fluids, showed rheumatoid factor activity. Immunocytes from the immunoblastic sarcoma were found to be the source of the monoclonal IgA protein.

Malignant progression of angioimmunoblastic lymphadenopathy

In a 79-year-old woman, the progression of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) to malignant lymphoma was observed within one year after diagnosis. Three biopsy specimens from lymph nodes and one tonsil, obtained at intervals of several months, showed an increasing destruction of the tissue architecture and the development of histological criteria for a lymphoid neoplasm, which at autopsy was confirmed as a malignant non-Hodgkin's lymphoma. The demonstration of a chromosomally abnormal clone in lymph node derived and the laboratory findings were in agreement with the histological changes and the sequential clinical deterioation. Initially, a symptom-free interval of eight months was achieved with prednisone therapy. However, this treatment failed after the malignant transformation had become evident.

Immunoblastic sarcoma: a clinical description

We reviewed the clinical records of 33 patients with Immunoblastic Sarcoma in order to further describe this disease clinically. Several common features were found. Thirty percent of the patients had a history of a prior immune disease or lymphoproliferative malignancy. Forty-four percent of the patients tested had a diffuse hypergammaglobulinemia. Lymphopenia (less than 1,000/mm3) was found in 45%, and anemia occurred in 73%. At initial presentation, 30% of the cases were clinically staged as either stage I or II, whereas 70% were found to be stage III or IV. Forty-nine percent of the patients had systemic symptoms at presentation. The median survival was 14 months. Advanced stage of disease, lymphopenia, and presence of systemic symptomatology were associated with significantly decreased survival times (p less than .05). We conclude that IBS is a clinical entity often associated with prior immune disease and/or diffuse hypergammaglobulinemia.

Lymphomatoid granulomatosis: a clinicopathologic study of 152 cases

A retrospective study of 152 cases of lymphomatoid granulomatosis (LYG) was undertaken to expand current knowledge about clinical manifestations and therapy, and to identify prognostic indicators in this disease. The major clinical and radiographic features and extra-pulmonary sites of involvement noted in previous studies were essentially confirmed in our study. Adverse prognostic factors included neurologic manifestations, and large numbers of atypical lymphoreticular cells within the pulmonary infiltrate. Unilateral chest lesions and large numbers of small lymphocytes and histiocytes within the infiltrate were associated with a better prognosis. Malignant lymphoma involving lymph nodes developed in 12% of patients. Almost two-thirds of patients have died and the median survival was only 14 months. No particular mode of therapy was found to be satisfactory for LYG, although there was some suggestion that corticosteroids may be useful. Randomized prospective studies are necessary for definitive recommendations regarding therapy.

Immunoblastic lymphadenopathy associated with methyldopa therapy: a case report

The case of a 71-year-old woman who developed generalized weakness, lymphadenopathy, and a skin rash during methyldopa therapy is described. The prompt disappearance of symptoms following the discontinuation of the drug implicates it in the initial triggering of the abnormal lymphoid proliferation. Shortly thereafter, florid immunoblastic lymphadenopathy developed, and the patient subsequently responded to corticosteroid therapy. The frequent occurrence of immunoblastic lymphadenopathy during or shortly after the administration of various therapeutic medications is emphasized. The nature of the disorder and its differential diagnosis are discussed.

Systemic lupus erythematosus and lymphoma

In 4 women lymphomas developed 2 months to 12 years after the onset of systemic lupus erythematosus. An association between the two diseases had previously been reported in 14 cases, in 6 of which the lymphoma either preceded or was diagnosed at the same time as the autoimmune disease. In systemic lupus erythematous early biopsy of suspect lymph-nodes is recommended.

Immunoblastic lymphadenopathy and adenocarcinoma of the pancreas: a case report

Immunoblastic lymphadenopathy developed 5 months before the clinical manifestation of an anaplastic adenocarcinoma of the pancreas in a 53-year-old male. The possible association and significance of this relationship, which has not been hitherto reported, is discussed.

Myelomatosis after phenytoin therapy: a chance association?

The occurrence of a monoclonal gammopathy followed by IgG-lambda multiple myeloma is described in a patient receiving diphenylhydantoin therapy for 20 years for epilepsy. Despite the known association between the drug and the development of immunosuppression and lymphoma, we regard the association recorded in this case to be coincidence. It is suggested that periodic examination of the serum proteins in patients receiving the drug may be useful in detecting early aberrations of the immune system in these individuals.

Angioimmunoblastic lymphadenopathy: a T-cell deficiency

The case of a 49-year-old man with the diagnosis of angioimmunoblastic lymphadenopathy is reported. The patient survived a stormy clinical course. The corticosteroids improved dramatically the clinical picture although the patient developed a staphylococcal septicemia. Before treatment immunological studies were done including quantitation of B and T-cells, antigen stimulation of lymphocytes in vitro, skin tests and skin window. Impairment of cell mediated immunity, decreased T-lymphocytes and increased B-lymphocytes were found. A decreased migration of lymphocytes in the skin window was also found compatible with immunosuppression. A possible presumptive pathogenetic mechanism is described although the cause of this recently described entity remains unknown.

Immunopathology of angioimmunoblastic lymphadenopathy

Eight patients with angioimmunoblastic lymphadenopathy have been studied by a variety of immunological and pathological techniques. They exhibited a spectrum of immunological reactivities that, in this small series, could be roughly correlated with survival. Those patients with relative B-cell predominance as shown by cell marker studies, histologically showed large numbers of plasma cells, and this pattern was associated in 3 of our patients with a survival of 3 years or more. T-cell predominance or both B- and T-cell depletion was associated histologically with large numbers of blast cells and eosinophils, but with few plasma cells. These patients responded poorly to therapy and had short survival times. One patient with B-cell predominance subsequently died of a histiocytic lymphoma.

Hypercatabolism of the third component of complement (C3) in angioimmunoblastic lymphadenopathy

A metabolic study with radioactively labelled C3 has been performed in a patient with angioimmunoblastic lymphadenopathy (AILD). The labelled protein was metabolized at a faster rate in the patient than in normal individuals. This indicates that the humoral immune system may be of pathogenetic significance in the AILD syndrome.

When "lymphoma" is not lymphoma: diagnosing immunoblastic lymphadenopathy

Immunoblastic lymphadenopathy, a newly described disease, is clinically similar to lymphoma but has a specific histologic picture. It usually does not have malignant potential and is best treated initially by corticosteroid in high doses. Chemotherapy is used when corticosteroid fails or when malignant conversion occurs.

Cytology and colchicine sensitivity of viable cells from lymph nodes with malignant lymphoma

Viable cell suspensions were prepared from 31 nodes diagnosed non-Hodgkin's malignant lymphoma, and from 30 non-malignant nodes. The cells were examined and counted by phase contrast microscopy. The suspensions were characterized by the percentage of large cells and by a colchicine-sensitivity index. The finding of more than 6% large cells or the finding of a sensitivity index of more than 30% was considered a positive test for a malignant lymphoma. According to these criteria there were 2 false positives in 30 reactive nodes and one false negative in 31 malignant nodes. Findings on 3 nodes diagnosed angioimmunoblastic lymphadenopathy suggested malignancy. The colchicinesensitivity index of blood lymphocytes seemed useful for monitoring lymphoma patients for leukemic involvement.

Amyloid deposition in immunoblastic lymphadenopathy

Two cases of immunoblastic lymphadenopathy are reported that in addition to having the usual histologic and electron microscopic appearance previously described exhibit perivascular and intersitial green polarization when stained with Congo red, indicating amyloid deposition. Electron microscopic examination confirmed the light microscopic findings. This finding may have significance in regard to etiology, progression, and treatment of this disease entity.

Angioimmunoblastic lymphadenopathy: an ultrastructural and immunologic study with review of the literature

Six cases of angioimmunoblastic lymphadenopathy (AIBL) are presented, detailed ultrastructural and immunohistologic studies of several involved organs are described, and the literature is reviewed. The features of the lesion are of normal immune reactive cells containing polyclonal cytoplasmic immunoglobulin. Large numbers of dying and degenerating cells result in accumulations of cell debris, corresponding to the characteristic interstitial material seen by light microscopy. Our studies confirm that the vascular changes are unique to lymph nodes, appear confined to postcapillary venules, and consist of endothelial cell hypertrophy and expansion of the vessel wall by basement membrane-like material, cellular debris and collagen fibers. No deposits of amyloid or antigen-antibody complexes were noted by ultrastructural or immunologic techniques. Our data reveal morphologic and laboratory features of a hyperimmune state but with paradoxical cutaneous anergy and decrease in blood (T) lymphocytes. We postulate that AIBL is an abnormal, but non-neoplastic immune reaction related to the autoimmune disorders, resulting from a loss of suppressor T cells with hyperfunction of the B lymphocyte system.

Classification of lymphomas

Malignant lymphomas are neoplasms of cells of the lymphoreticular or immune system. Classification of these neoplasms has long been controversial and confusing. In recent years, considerable progress has been made in establishing useful and prognostically significant classifications of lymphomas. Currently, lymphomas may be divided into two main groups: Hodgkin's disease and non-Hodgkin's lymphomas. The Rye classification of Hodgkin's disease is now widely accepted and used throughout most of the world. In contrast, considerable conflict exists about the schemes of non-Hodgkin's lymphomas. The traditional classifications of non-Hodgkin's lymphomas currently used by most pathologists are based purely on morphologic grounds, and, despite the fact that they may be conceptually incorrect, they have often been shown to be useful for clinicopathologic studies. New or modern but yet untested schemes based not only on morphologic criteria, but also on recent immunologic techniques, have been proposed. This work will review the classifications of Hodgkin's disease and the non-Hodgkin's lymphomas, emphasizing the currently used schemes, describe the major modern classifications of lymphomas, and discuss and illustrate the subclasses of lymphomas and the differential diagnoses of the various types of lymphomas from nonlymphomatous proliferations which may mimic them.

Angioimmunoblastic lymphadenopathy: pleural-pulmonary disease

A 48-year-old female with angioimmunoblastic lymphadenopathy is described. Her disease was complicated by pleuritic chest pain, an exudative pleural effusion and pulmonary infiltrates attributable to underlying pleural-pulmonary angioimmunoblastic lymphadenopathy.

Immunoblastic lymphadenopathy with pulmonary infiltrates, hypocomplementemia and vasculitis. A hyperimmune syndrome

A detailed description of the clinical and morphologic characteristics of four patients with immunoblastic lymphadenopathy, pulmonary infiltrates, hypocomplementemia and vasculitis is presented. Noteworthy in the patients described here is the clinical similarity to patients with collagen-vascular diseases and systemic drug reactions. The frequent occurrence of pulmonary symptoms, bilateral interstitial infiltrates and pleural effusions is emphasized. The morphology suggests stimulation of the immune system by antigenic agents, and the low complement levels and the presence of vasculitis suggest that circulating immune complexes may be present. Immunoblastic lymphadenopathy may represent a syndrome in which the adenopathy is but a nonspecific part of a systemic hyperimmune response to unknown antigens. The clinical course of the patients reviewed suggests that supportive treatment and corticosteroids constitute the safest therapeutic approach.

Angioimmunoblastic lymphadenopathy with dysproteinemia

Three cases of angioimmunoblastic lymphadenopathy with dysproteinemia are reported which illustrate the characteristic clinico-pathological features. These cases also provide information relating to the ultrastructure of the interstitial acidophil material, the histopathological spectrum, where treatment has been attempted, and an incidence figure for an Australian community. Detailed immunological investigations in one case suggest that the disease is a primary B-lymphocyte abnormality.

Adjuvant treatment with levamisole in cancer: a review of experimental and clinical data

Animal and human studies of adjuvant treatment with levamisole in cancer are reviewed and discussed. From the animal data it is concluded that the activity of levamisole is dose-dependent, more effective on slow-growing tumors, affects metastasis formation, preferentially is best when levamisole is used as an adjuvant to the usual cytoreductive treatments and that tumor enhancement is not expected. Clinical findings are put into perspective of the animal data and the most appropriate clinical situations are indicated.