Angioimmunoblastic lymphadenopathy with paraproteinemia: a T- and B-cell disorder

Kaposi's Sarcoma Complicating Immunosuppressive Therapy for Angioimmunoblastic Lymphadenopathy with Dysproteinemia

Cutaneous and visceral dissemination of Kaposi's sarcoma (KS) occurred in a patient with angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) who had been treated with combination chemotherapy. Three other cases of KS complicating immunosuppressive therapy of AILD have been reported in the literature, and there is evidence to indicate that AILD displays features which are known to predispose to KS. Like in other subjects with profound immunodeficiency (e.g. in young homosexual men), in our patient KS pursued an unusually aggressive course, with involvement of lymph nodes and internal organs as well as the skin. It is concluded that the risk of developing severe KS is a further reason to avoid aggressive combination chemotherapy in patients with AILD, particularly in those of Jewish or Mediterranean ancestry. Even the use of corticosteroids should be reduced to a minimum to avoid immunosuppression, and a conservative approach to treatment seems advisable.

Skin lesions and neutrophilic leukemoid reaction in a patient with angioimmunoblastic T-cell lymphoma: a case report and review of the literature

Here, we present a 53-year-old man with angioimmunoblastic T-cell lymphoma accompanied by skin lesions (vesicles, papulovesicles, and miliary papules symmetrically distributed on extremities and trunk, with more distal lesions increasing in severity). Routine blood tests showed a white blood cell count of 58.97 × 109/L (Neutrophils% 91.64%).

Composite EBV negative peripheral T-cell lymphoma and diffuse large B-cell lymphoma involving the ileum: a case report and a systematic review of the literature

We report a case of an intestinal peripheral T-cell lymphoma (PTCL) with a concurrent diffuse large B-cell lymphoma (DLBL) involving the ileum and a regional lymph node. The patient presented with an abdominal mass. The terminal ileum showed a diffuse and monotonous population of small CD3-positive T cells. The T-cell receptor gamma (TCRgamma) gene was rearranged by PCR while the immunoglobulin heavy chain (IgH) gene was not. A separate section of the ileum showed a colliding large B-cell proliferation. The regional lymph node showed a diffuse proliferation of large centroblasts positive for CD20 and CD79a admixed with small T cells and showed a rearranged IgH receptor gene without evidence of a clonally rearranged TCRgamma gene. Both the PTCL and DLBL components were negative for EBV. A review and analysis of the pertinent literature describing composite T- and B-cell lymphomas is performed and reported.

Genetic changes in atypical hyperplasia and lymphoma with angioimmunoblastic lymphadenopathy and dysproteinaemia in the same patients

The transition between atypical hyperplasia and lymphoma with angioimmunoblastic lymphadenopathy and dysproteinaemia (AILD) was studied in serial lymph node biopsy specimens from five patients using DNA analysis with Southern blot analysis, polymerase chain reaction, chromosomal analysis, and immunophenotyping. The chromosomal analysis showed additional abnormalities as the disease progressed to those present initially, and immunological staining showed a corresponding increase in the numbers of CD4- and Ki67-positive cells. In the first biopsy from each patient a diagnosis of atypical hyperplasia with AILD was made and lymphoma excluding by the finding of only a few atypical lymphoid cells and the preservation of follicles with germinal centres. DNA analysis of lymph nodes at this stage showed either germ lines or oligoclonal rearrangements of the T-cell receptor (TCR) and immunoglobulin heavy chain genes. In the final biopsy, when a diagnosis of lymphoma with AILD was made, either a monoclonal rearrangement of the TCR was observed or one of the rearranged bands had increased in density. These results suggest selective proliferation of a clone of abnormal cells may account for the progression of atypical hyperplasia to lymphoma with AILD.

Angioimmunoblastic lymphadenopathy following Kaposi's sarcoma

The close relationship of Kaposi's sarcoma (KS) with other lymphoproliferative disorders is a poorly understood, but well documented, phenomenon. A case is presented of a 68-year-old woman with the classical form of cutaneous KS in whom disappearance of the lesions after treatment was shortly followed by the development of angioimmunoblastic lymphadenopathy, pursuing a fulminant course to death. Postmortem examination revealed diffuse involvement of the marrow, spleen, liver, and lymph nodes by the immunoblastic proliferation. The close association of these two conditions may represent more than a chance occurrence. The appearance of a constellation of nonspecific symptoms suggestive of a lymphoproliferative disorder in debilitated patients with KS should alert the physician to the possibility of the development of this rare complication.

Clonality of angioimmunoblastic lymphadenopathy and implications for its evolution to malignant lymphoma

To investigate the relationship of the lymphoid hyperplasia of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) to supervening malignant lymphoma, we subjected DNA from lymph nodes and peripheral blood mononuclear cells from five AILD patients to Southern blot analysis to detect clonal rearrangements of immunoglobulin and T-cell receptor genes. Lymph nodes and peripheral blood from AILD patients were found to contain clones of lymphoid cells harboring either immunoglobulin or T-cell receptor gene rearrangements that, in some instances, regressed during the course of disease. A lymph node from one patient was involved by immunoblastic lymphoma and manifested an additional gene rearrangement pattern not seen in premalignant specimens from that patient. In contrast, DNA obtained from normal peripheral blood mononuclear cells and 11 examples of other forms of lymphoid hyperplasia showed no gene rearrangements. As a disorder of cellular immunoregulation in which lymphoid cells may escape normal growth controls, AILD provides a natural model to dissect stages of lymphomagenesis in man.

Effect of cyclophosphamide therapy on oncogene expression in angioimmunoblastic lymphadenopathy

The expression of four cellular oncogenes was studied by means of northern blot analysis of messenger RNA in peripheral-blood mononuclear cells from patients with angioimmunoblastic lymphadenopathy (AILD). On average, cells from patients with AILD and from those with systemic lupus erythematosus (SLE) expressed significantly more N-ras and significantly less c-fos mRNA than did cells from healthy controls. Expression of these cellular oncogenes was most abnormal in patients with the most severe disease. In contrast, increased levels of c-myc mRNA were found in patients with SLE but not in those with AILD. Administration of cyclophosphamide to patients with AILD was followed by return to normal of both N-ras and c-fos expression.

Peripheral T-cell lymphomas: histologic, immunohistologic, and clinical characterization

A review of 40 cases of peripheral T-cell lymphoma identified at our institution between March 1983 and December 1985 revealed a clinically, histologically, and immunologically diverse group of neoplasms that were difficult to classify by conventional histomorphologic criteria for non-Hodgkin's lymphomas. These lymphomas were frequently extranodal at the time of initial manifestation (52%), and their clinical aggressiveness correlated with three major histologic categories--small lymphocytic, diffuse mixed, and large cell. Of the 40 lymphomas, 18 exhibited distinctive histologic features that allowed assignment of these cases into one of four subgroups: (1) angioimmunoblastic lymphadenopathy, (2) lymphomatoid granulomatosis, (3) Hodgkin's-like disease, and (4) Lennert's lymphoma (lymphoepithelioid lymphoma). Study of all our cases that fulfilled the morphologic criteria for lymphomatoid granulomatosis or angioimmunoblastic lymphadenopathy by using immunologic methods for identification of B-cell and T-cell antigens has shown these neoplasms to be peripheral T-cell lymphomas. Therefore, we now consider these earlier proposed entities to be distinct histologic variants of peripheral T-cell lymphoma.

Monoclonal hypergammaglobulinemia without malignant transformation in angioimmunoblastic lymphadenopathy with dysproteinemia

A patient with angioimmunoblastic lymphadenopathy with dysproteinemia had a monoclonal IgG hypergammaglobulinemia. In contrast to previous reports, the development of a monoclonal paraprotein in the setting of angioimmunoblastic lymphadenopathy with dysproteinemia did not herald a transformation to malignancy. The patient improved clinically and the monoclonal gammopathy disappeared when the patient was treated with prednisone. The relationship of these findings to current concepts regarding the cause of angioimmunoblastic lymphadenopathy with dysproteinemia is discussed.

Angioimmunoblastic lymphadenopathy with dysproteinemia. Circulating immune complexes and the review of 18 cases

Eighteen patients with angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) have been analyzed by reviewing all available biopsy, laboratory, and clinical data. Because of features suggesting the presence of circulating immune complexes (CIC), CIC serial sample determinations were performed throughout their disease in available patients. Age, sex, and clinical and laboratory characteristics were consistent with previously reported series. Six of 18 (33%) patients having a drug exposure associated with onset or exacerbation of symptoms demonstrated a significantly decreased survival (P less than 0.02). Achievement of complete remission was a significant indicator of longevity (P less than 0.001). Only one patient (6%) developed diffuse histiocytic lymphoma. Elevated CIC were detected in the four patients tested. In two patients fluctuating CIC levels could clearly be correlated to clinical remission or exacerbation. Despite the small number of patients tested, it was concluded tha CIC may provide useful information for therapy selection, prediction of relapse, and further insight into pathogenetic mechanisms in AILD.

Histological, immunohistological and autopsy findings in lymphogranulomatosis X (including angio-immunoblastic lymphadenopathy)

172 cases of lymphogranulomatosis X (LgX) were studied by light microscopy. In 53 cases immunohistological techniques for detecting intracytoplasmic immunoglobulins were applied. In the lymph nodes of all cases the nodal architecture was found to be effaced. Active germinal centres were absent, and there was a generalized, markedly increased proliferation of epithelioid venules. A polymorphic infiltrate was present in all cases. It was dominated by immunoblasts in 14%, by plasma cells in 16%, by epithelioid cells in 23% and by lymphocytes in 6% of the cases. In the remaining 41% of the cases no special type of cell predominated (mixed cell type of LgX). The clusters of clear cells present in some cases with immunoblastic predominance did not stain for intracytoplasmic immunoglobulins; in contrast, the basophilic immunoblasts exhibited a polyclonal Ig pattern. In some of the cases with lymphocytic predominance most of the lymphocytes showed abundant cytoplasm with azurophil granules. Transformation into malignant lymphoma was proven at autopsy in 5 of 38 cases (13.2%). Malignant transformation (biopsy and autopsy material) was confirmed in a total of 11 of 172 cases (6.4%) and suspected in an additional 7%. Among the malignant lymphomas were one immunologically proven B-immunoblastic lymphoma, one peripheral T cell lymphoma and 5 cases of Hodgkin's disease. An association between LgX and carcinoma was histologically verified in 7 cases. 26 cases with active germinal centres and 11 cases with only locally pronounced vascularization but with histological and cytological changes that were otherwise similar to LgX were designated as hyperimmune reactions (HR). These cases had a significantly better prognosis. Two cases that presented as HR with active germinal centres later developed into LgX. It is suggested that the disappearance of active germinal centres is important in the pathogenesis of LgX. The possibility that this may correspond morphologically to an alteration of different components of the T-cell system is discussed.

Kaposi's sarcoma and angioimmunoblastic lymphadenopathy

Kaposi's sarcoma (KS) and angioimmunoblastic lymphadenopathy (AILD) are exceptionally rare neoplastic diseases, although the former has recently been more frequently reported among certain populations, and is lately a topic for extensive medical and investigational interest. This case is unique in that it describes an association between KS and AILD. Such an association raises the question of a common pathogenic mechanism. The authors believe that predisposition to each of both diseases may be related to acquired immune deficiency which in turn may be induced by specific viral infections.

Angioimmunoblastic lymphadenopathy with associated selective myeloid hypoplasia

Angioimmunoblastic lymphadenopathy is a disease characterized systemic symptoms, lymphadenopathy, hepatosplenomegaly and polyclonal hypergammaglobulinemia. Hematologic abnormalities are common, especially anemia, which is often Coombs positive, and lymphocytopenia. This report cites a case of angioimmunoblastic lymphadenopathy associated with selective hypoplasia of the myeloid line and normal maturation of all other marrow-derived cell lines. Possible relationships of this finding to the immunologic abnormalities associated with angioimmunoblastic lymphadenopathy are discussed.

Blood findings in lymphogranulomatosis X

A quantitative analysis of leukocytes in the peripheral blood of 16 patients with lymphogranulomatosis X revealed the following findings: The number of total leukocytes, monocytes, neutrophils, and eosinophils varied considerably and showed no clear common tendency. Blood basophils were found to be clearly increased with a mean value of 0.17 +/- 0.18 X 10(9)/1 as compared to 55 normal donors (0.04 +/- 0.01 X 10(9)/1). Lymphocyte counts were within the normal range. Lymphopenia was seen in 2 patients. Lymphocytes with azure granules which encompass T-suppressors were found to exceed normal values by a factor of 15. In 14 cases a variable number of hyperbasophil cells were present. Lymphogranulomatosis X seems to present with a characteristic blood picture which might be of diagnostic aid.

Angiokines, angiogenesis and angiolymphoproliferative syndromes (ALPS)

In earlier experiments we had noted that transformed and leukemic leukocytes produced an RNA-rich angiogenic lymphokine. The formation of capillaries is a stepwise process in which reticulum cells first become detached and attracted to a site (mobilization and migration along a reticulin network). This is followed by local proliferation and finally by elongation and alignment against a basal membrane in tubular geometry. Coincidental with the last step is a biochemical and immunochemical differentiation of the endothelial cells manifested by the appearance of alkaline phosphatase, angiotensin-converting enzyme, factor VIII and the generation of receptors for thrombin as well as the capacities to produce prostacyclin and fibronectin on demand. It is postulated that there may be not one but several angiogenic lymphokines (angiokines) for each step of capillary development. Angiokine 1 (AK1) for the mobilization-chemotactic-migration, AK2 for the local proliferative, and AK3 for differentiating-morphogenic events. The above postulate aids in the classification and understanding of a number of angiolymphoproliferative syndromes since these reflect different disorders of the stepwise vessel formation. The association and the simultaneous proliferation of vascular and lymphoid elements is a feature that a number of lymphoproliferative disorders, of otherwise differing nature, have in common. To this effect they have been grouped in this study as angiolymphoproliferative syndromes (ALPS). These are a group of prelymphomatous or prelymphomogenic clinicopathologic entities in which proliferation of a lymphoid element (cell) is coupled with the accelerated development of blood capillaries and postcapillary venules.