1
|
Yeh WZ, Muthusamy S, McKelvie P, Collins S, French A, Filshie R, Sutherland T, Trost N, Reardon K. Lymphoma, a great imitator in neurology. J Clin Neurosci 2020; 73:308-310. [PMID: 32081598 DOI: 10.1016/j.jocn.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 12/15/2019] [Accepted: 02/08/2020] [Indexed: 12/14/2022]
Abstract
The title "great imitator" refers to conditions which can cause varied manifestations and mimic many diseases. Lymphoma is worthy of this title. We describe three cases of lymphoma in which lymphoma mimicked other diseases causing neurological dysfunction, specifically sarcoidosis, vasculitis and infection respectively. Case 1 was a 66-year-old man with subacute progressive diplopia and gait disturbance and investigations revealing a supratentorial para-falcine soft tissue lesion, mid-thoracic cord enhancement and right axillary mass and an elevated serum ACE. Right axillary mass core biopsy was diagnostic of Burkitt lymphoma. Case 2 was a 50-year-old man with several weeks of constitutional symptoms and development of lower limb weakness and numbness, urinary retention and confusion while in hospital. MRI brain demonstrated multi-territory cerebral infarcts. Intravascular lymphoma was diagnosed on random skin biopsy. Case 3 was a 65-year-old man with several weeks of headache and diplopia on a background of previously treated Burkitt lymphoma. CSF analysis showed a lymphocytic pleocytosis and markedly low glucose with cytologic analysis negative for malignancy. Investigations for an infective cause were negative. FDG-PET demonstrated marked, disseminated spinal and cranial leptomeningeal disease and a multi-focal, intra-dural relapse of Burkitt lymphoma was diagnosed. The varied manifestations in our cases demonstrate the ability for lymphoma to mimic infective, inflammatory, granulomatous (including sarcoidosis) and neoplastic aetiologies. An elevated serum ACE appears insufficiently diagnostic to confirm sarcoidosis and tissue for histological examination should be sought whenever possible. When the diagnosis is uncertain, the possibility of this great imitator should be considered, especially for multi-focal disease.
Collapse
Affiliation(s)
- Wei Zhen Yeh
- Department of Neurology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy VIC 3065, Australia.
| | - Subramanian Muthusamy
- Department of Neurology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy VIC 3065, Australia
| | - Penny McKelvie
- Department of Anatomical Pathology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy VIC 3065, Australia
| | - Steven Collins
- Department of Neurology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy VIC 3065, Australia
| | - Ann French
- Department of Neurology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy VIC 3065, Australia
| | - Robin Filshie
- Department of Haematology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy VIC 3065, Australia
| | - Tom Sutherland
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy VIC 3065, Australia; Faculty of Medicine, University of Melbourne, Parkville, Australia
| | - Nicholas Trost
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy VIC 3065, Australia
| | - Katrina Reardon
- Department of Neurology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy VIC 3065, Australia
| |
Collapse
|
2
|
Abaroa-Salvatierra A, Shaikh B, Deshmukh M, Alweis R, Patel A. Calcitriol-mediated hypercalcemia in a patient with bilateral adrenal non-Hodgkin's B-cell lymphoma case report. J Community Hosp Intern Med Perspect 2016; 6:30381. [PMID: 27124160 PMCID: PMC4857720 DOI: 10.3402/jchimp.v6.30381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 02/04/2016] [Accepted: 02/08/2016] [Indexed: 01/23/2023] Open
Abstract
Calcitriol-mediated hypercalcemia is a frequent manifestation of hematological malignancies. However, there are a few reports of cases presenting with increased angiotensin-converting enzyme (ACE) level, which suggests a possible mechanism similar to that of granulomatous diseases. We present a patient with hypercalcemia, normal parathyroid hormone, and parathyroid hormone-related protein levels but high calcitriol and ACE levels that, after further investigation, was diagnosed with bilateral adrenal non-Hodgkin's B-cell lymphoma. Primary adrenal lymphoma represents only 1% of all non-Hodgkin's lymphomas and is usually asymptomatic but should be considered by clinicians among the malignancies that cause calcitriol-mediated hypercalcemia.
Collapse
Affiliation(s)
| | - Bilal Shaikh
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Mrunalini Deshmukh
- Department of Endocrinology and Diabetes Center, Reading Health System, West Reading, PA, USA
| | - Richard Alweis
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Arti Patel
- Department of Endocrinology and Diabetes Center, Reading Health System, West Reading, PA, USA
| |
Collapse
|
3
|
"The Great Mimicker": An Unusual Etiology of Cytopenia, Diffuse Lymphadenopathy, and Massive Splenomegaly. Case Rep Med 2015; 2015:637965. [PMID: 26579198 PMCID: PMC4633558 DOI: 10.1155/2015/637965] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/04/2015] [Indexed: 11/18/2022] Open
Abstract
Sarcoidosis is an idiopathic multisystem disease characterized by the formation of noncaseating granulomas. It frequently presents with pulmonary infiltrates and bilateral hilar and mediastinal lymphadenopathy. Splenic involvement is common, but massive splenomegaly is a rare occurrence. Sarcoidosis is known as "the great mimicker" (or "the great imitator") since it exhibits a myriad of symptoms, mimicking other inflammatory, infectious, and neoplastic conditions, including lymphoma. Herein, we report the case of a 44-year-old male patient who was found to have bicytopenia, hypercalcemia, diffuse lymphadenopathy, and massive splenomegaly, a constellation of findings suggestive of underlying lymphoma. Interestingly, lymph node biopsy showed noncaseating granulomas suggestive of sarcoidosis, without evidence of malignancy.
Collapse
|
4
|
[Sarcoidosis-lymphoma syndrome]. Med Clin (Barc) 2015; 145:277-8. [PMID: 25771337 DOI: 10.1016/j.medcli.2015.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 01/16/2015] [Accepted: 01/22/2015] [Indexed: 11/21/2022]
|
5
|
|
6
|
Kaiser PK, Lowder CY, Sullivan P, Sanislo SR, Kosmorsky GS, Meziane MA, Rice TW, Smith SD, Meisler DM. Chest computerized tomography in the evaluation of uveitis in elderly women. Am J Ophthalmol 2002; 133:499-505. [PMID: 11931783 DOI: 10.1016/s0002-9394(02)01333-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To describe the usefulness of chest computerized tomography (CT) in the evaluation of uveitis in elderly women and the clinical characteristics of patients with an abnormal chest CT scan. DESIGN Prospective noncomparative case series. METHODS We evaluated 30 elderly women, aged 61-83 years, with chronic iritis, vitritis, or choroiditis and with no definitive cause for their uveitis. All patients underwent a battery of diagnostic laboratory studies and chest CT. RESULTS The diagnostic examination in most patients included serum angiotensin converting enzyme level, serum lysozyme, rapid plasma reagin level, fluorescent treponemal antibody-absorption test, purified protein derivative skin test, and chest x-rays. Chest CT performed on all patients showed parenchymal, mediastinal, and/or hilar adenopathy in 17 patients (57%). Histopathologic confirmation of sarcoidosis with noncaseating granulomas in the biopsy specimens was obtained in 14 patients: eight by mediastinoscopy, two by bronchoscopy, two by conjunctival biopsy, one by nasal biopsy, and one by vitreous biopsy. CONCLUSIONS Chest CT can be useful in elderly female patients with chronic uveitis for identifying mediastinal lymphadenopathy and other lesions suggestive of sarcoidosis, as well as to help guide tissue confirmation and to rule out other diagnoses including lymphoma.
Collapse
Affiliation(s)
- Peter K Kaiser
- Division of Ophthalmology, Cole Eye Institute, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Dunphy CH, Panella MJ, Grosso LE. Low-grade B-cell lymphoma and concomitant extensive sarcoidlike granulomas: a case report and review of the literature. Arch Pathol Lab Med 2000; 124:152-6. [PMID: 10629150 DOI: 10.5858/2000-124-0152-lgbcla] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Sarcoidlike granulomas may occur in association with Hodgkin lymphoma and non-Hodgkin lymphoma. The granulomas may be concomitant and so extensive that they obscure the malignant process. In addition, a sarcoidosis-lymphoma syndrome has been described in which there appears to be a relationship between sarcoidosis and the development of a lymphoproliferative disorder. We report a case of a low-grade B-cell lymphoma with concomitant extensive sarcoidlike granulomas. The patient had no diagnostic clinical evidence of sarcoidosis, although she had an elevated serum calcium level and increased serum angiotensin converting enzyme activity. Increased serum calcium and serum angiotensin-converting enzyme activity have been associated with clinical sarcoidosis but have also occasionally been described in association with Hodgkin lymphoma and non-Hodgkin lymphoma without evidence of sarcoidosis. We describe our findings and illustrate the usefulness of immunoperoxidase immunophenotyping techniques in such a case.
Collapse
Affiliation(s)
- C H Dunphy
- Division of Hematopathology, Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | | | | |
Collapse
|
8
|
Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 35-1996. A 57-year-old woman with fever, sweats, neuropathy, and multiple pulmonary nodules. N Engl J Med 1996; 335:1514-21. [PMID: 8890104 DOI: 10.1056/nejm199611143352008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
9
|
Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 31-1995. A 43-year-old man with multifocal neurologic problems and confusion. N Engl J Med 1995; 333:992-9. [PMID: 7666921 DOI: 10.1056/nejm199510123331509] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
10
|
Devogelaer JP, Lambert M, Boland B, Godfraind C, Noel H, Nagant de Deuxchaisnes C. 1,25-Dihydroxyvitamin D-related hypercalcemia in lymphoma: two case reports. Clin Rheumatol 1990; 9:404-10. [PMID: 2261743 DOI: 10.1007/bf02114405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We report two patients with non-Hodgkin's lymphoma in whom hypercalcemia and elevated 1,25 dihydroxyvitamin D (1,25-(OH)2D3) levels developed in the absence of any lytic bone lesions. Hypercalcemia responded only transiently to glucocorticoids which were ill tolerated. Intravenous APD administration was needed to circumvene hypercalcemia. Humoral hypercalcemia of malignancy is discussed. Our cases confirm that hypercalcemia associated with elevated 1,25-(OH)2D3 may occur in malignant lymphoma.
Collapse
Affiliation(s)
- J P Devogelaer
- Department of Rheumatology, St-Luc University Hospital, Louvain University, Brussels, Belgium
| | | | | | | | | | | |
Collapse
|
11
|
Carr PL, Singer DE, Goldenheim P, Bernardo J, Mulley AG. Noninvasive testing of asymptomatic bilateral hilar adenopathy. J Gen Intern Med 1990; 5:138-46. [PMID: 2156032 DOI: 10.1007/bf02600516] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The diagnostic strategy for asymptomatic patients with persistent bilateral bilar adenopathy often involves invasive procedures. The authors used Bayesian analysis to: 1) estimate the relative prevalences of diseases causing bilateral bilar adenopathy; 2) assess changes in the prevalence of disease by race, the presence of other clinical symptoms, and geography; and 3) determine the value of relevant noninvasive tests, including the angiotensin-converting enzyme (ACE) assay, gallium scan, and purified protein derivative (PPD), in order to assess when a strategy of watchful waiting is appropriate. The analysis indicated that the ACE assay, particularly when paired with the PPD, can identify many patients who might safely be managed without immediate invasive biopsy. Patients who are ACE+ and PPD- have an estimated probability of sarcoidosis of 0.95 or greater; patients who are ACE- and PPD+ have a probability of tuberculosis of 0.86 if black, 0.79 if white. In contrast, gallium scanning has no diagnostic role in this clinical situation. Bronchoscopic or mediastinoscopic biopsy has a limited role for patients who are ACE+ PPD- or ACE- PPD+ because of limited sensitivity. Patients who are both ACE- and PPD-, particularly if white, may have a high enough risk of lymphoma to consider invasive biopsy.
Collapse
Affiliation(s)
- P L Carr
- Department of Medicine, Massachusetts General Hospital, Boston 02114
| | | | | | | | | |
Collapse
|
12
|
|
13
|
Ismail SM, Myers K. Infiltrative myeloid metaplasia: an unusual cause of gastric outlet obstruction. J Clin Pathol 1989; 42:1112-3. [PMID: 2584415 PMCID: PMC501878 DOI: 10.1136/jcp.42.10.1112-b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
14
|
Zachëe P, Geboers M, Neels H, Beelaerts W, Scharpé S. Serum angiotensin converting enzyme: a possible marker in Lennert's lymphoma? J Clin Pathol 1989; 42:1112. [PMID: 2555399 PMCID: PMC501877 DOI: 10.1136/jcp.42.10.1112-a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|