Clinical Mimics of Lymphoma

An unusual pseudolymphoma in the context of necrotizing fasciitis: A case report

RATIONALE

The diagnosis of lymphoma in routine diagnostics can be challenging due to clinical, morphological and immunphenotypical overlap with unusual reactive processes termed "pseudolymphomas."

PATIENT CONCERNS

45-year-old male that underwent surgical debridement for a necrotizing fasciitis of the thigh with concomitant excision of a regional lymph node.

DIAGNOSES

The lymph node demonstrated an architecture-effacing activation and proliferation of lymphoblasts and was initially misdiagnosed as an aggressive lymphoma. Only in consideration of the clinical context and with the help of additional immunohistochemical and molecular analyses the final diagnosis of a reactive lymphadenopathy could be made.

INTERVENTIONS

No further therapy was required after the final diagnosis of a reactive lymphadenopathy was made.

OUTCOMES

The clinical follow-up was unremarkable, with no evidence of residual disease after 6 months.

LESSONS

This case report adds the parafollicular activation and proliferation of blasts and plasmablasts in the drainage area of an active infection to the spectrum of "pseudolymphomas" and reiterizes the importance of placing histopathological findings in the proper context.

Role of EBUS-TBNA in Non-Neoplastic Mediastinal Lymphadenopathy: Review of Literature

Mediastinal lymphadenopathy is a condition in which one or more mediastinal lymph nodes are enlarged for malignant or benign causes, generally more than 10 mm. For a long time, the only way to approach the mediastinum was surgery, while in last decades endoscopic techniques gained their role in neoplastic diseases. At the present time, EBUS is the technique of choice for studying the mediastinum in the suspicion of cancer, while there are not strong indications in guidelines for the study of benign mediastinal lymphadenopathy. We reviewed the literature, looking for evidence of the role of EBUS in the diagnostics of non-neoplastic mediastinal lymphadenopathy, with special regard for granulomatous disease, both infectious and non-infectious. EBUS is a reliable alternative to surgery in non-neoplastic mediastinal lymphadenopathy, even if more evidence is needed for granulomatous diseases other than tuberculosis and sarcoidosis.

The Pattern of Superficial Lymphadenopathy on Fine Needle Aspiration Cytology in Clinical Practice in Islamabad

Background: In adults, lymph nodes are not normally palpable. A number of patients with asymptomatic lymphadenopathy never visit physicians for the condition, and thus, this important sign is often missed by the medical practitioner if it is not the presenting complaint. The incidence of lymphadenopathy is suggested to be increasing. While lymphadenopathy is benign and self-limiting in most patients, the underlying disease may range from treatable infectious etiology to malignant neoplasms. In most cases clinical examination and history guide towards the cause of lymphadenopathy. In recent years, fine needle aspiration cytology (FNAC) has become an easy clinical tool (with or without the assistance of CT, MRI, and ultrasound) for the diagnosis of the underlying cause of lymphadenopathy.

Aims and objectives: To find out the cytomorphological pattern in superficial lymphadenopathy with the help of FNAC.

Materials and methods: This descriptive cross-sectional study was conducted at HBS General Hospital, Islamabad from January 2017 to June 2019. Patients presenting with superficial lymphadenopathy were included in the study. FNAC was performed by the pathologist, histopathological reports were examined and analyzed using Statistical Package for the Social Sciences (SPSS) version 22 (IBM Corp., Armonk, NY). 

Results: Six hundred and thirty-two patients underwent FNAC. Tuberculous lymphadenitis was the most common diagnosis (56.1%) followed by reactive hyperplasia (28.29%). The sample showed metastatic malignancy 3.36% and lymphoma 2.05%. Cervical lymphadenopathy was the most common site for TB (49.36%). Metastatic cancer observed in cervical lymph nodes was 3.16% and lymphoma was 1.74%.

Conclusion: FNAC is recognized as a simple and safe diagnostic technique that can diagnose cases of superficial and deep lymphadenopathy easily. The most common cause of superficial lymphadenopathy in our study was tuberculosis with cervical lymph nodes.

Mitochondria targeted near-infrared chemodosimeter for upconversion luminescence bioimaging of hypoxia

We report a mitochondria-targeted near-infrared probe (NRh-O) for frequency upconversion luminescence (FUCL) imaging of hypoxia. Under hypoxic conditions, NRh-O rapidly responds to release the FUCL product NRh (λ_ex/em = 850/825 nm) with high sensitivity and selectivity in mitochondria. This highlights the potential application of a hypoxia-responsive probe in early clinical diagnosis.

Multicentric Plasma-Cell Type Castleman Disease Masquerading As Hodgkin Lymphoma: A Case Report

Castleman disease (CD), or angiofollicular hyperplasia, or giant lymph node hyperplasia, is a heterogeneous benign lymphoproliferative disorder of unknown etiology. It has three distinct histologic subtypes (hyaline vascular, plasma cell, and mixed hyaline vascular plasma cell types) as well as unicentric Castleman disease (UCD) and multicentric Castleman disease (MCD) variants. In the unicentric form, the disease is confined to one anatomical lymph node and usually with no systemic symptoms. However, in the multicentric form (further subdivided into idiopathic MCD, human herpes virus-8-associated MCD, and POEMS-associated MCD), lymphadenopathy is more generalized with more aggressive systemic symptoms mimicking a malignant lymphoma. Therefore, this case report aims to underscore the importance of immunohistochemical evaluation as an indispensable ancillary technique to routine histopathological examination of a lymph node biopsy specimen, as a gold standard for definitive diagnosis of proliferative lymph node lesions.

Rosai-Dorfman disease: a rare presentation with para-aortic and mesenteric lymphadenopathy, hepatosplenomegaly and ascites

Background

Rosai-Dorfman disease (RDD) is a rare but well-defined, histiocytic proliferative disorder with massive lymphadenopathy.

Case presentation

Herein we present the case of a 22-month-old girl with abdominal, neutrophilia, anemia, ascites, hepatosplenomegaly and fever. There were multiple enlarged mesenteric and para-aortic lymph nodes on abdominal ultrasonography and computer tomography scan. Microscopic examination of mesenteric lymph nodes showed dilation of the lymph sinuses occupied by lymphocytes, plasma cells, and many histiocytes. These histiocytes showed emperipolesis within their cytoplasm. With the diagnosis of RDD, prednisolone was started and good response was seen. However, splenomegaly and pancytopenia presented at follow up, and, after several hospital admissions, she died of sepsis.

Conclusions

RDD should be considered in the differential diagnosis of pediatric lymphadenomegaly. Although most patients experience favorable prognosis, some fatalities occur due to progression and dissemination of the disease.

Thoracic lymphadenopathy as possible predictor of the onset of interstitial lung disease in systemic sclerosis patients without lung involvement at baseline visit: A retrospective analysis

Objective:

To evaluate clinical, laboratory, or radiographic predictors of the onset of interstitial lung disease in systemic sclerosis.

Methods:

Sixty-five out of 220 systemic sclerosis outpatients, without interstitial lung disease at baseline and with ⩾3 chest high resolution computed tomography scans during follow-up were recruited. Thoracic lymphadenopathy and interstitial lung disease were assessed by chest high resolution computed tomography. Hazard ratio (95% confidence interval) of interstitial lung disease occurrence was assessed by Cox regression models, adjusting patient’s demographics and disease characteristics. Sensitivity, specificity, and accuracy of the interstitial lung disease predictors were evaluated by receiver operating characteristic analysis.

Results:

The development of interstitial lung disease was observed in 44/65 (68%) patients. Thoracic lymphadenopathies was detected in 40/65 (61%) patients, of whom 36 (82%) developed interstitial lung disease, but only four patients with thoracic lymphadenopathies did not develop ILD at last visit of follow-up (19%) (p = 0.0001). Adjusted hazard ratio of systemic sclerosis-interstitial lung disease onset was 5.8 (95% confidence interval, 2.0–16.5) for thoracic lymphadenopathy, which preceded by 108 ± 98 weeks the systemic sclerosis-interstitial lung disease detection. Thoracic lymphadenopathy had 84% specificity, 81% sensitivity, and 0.82 accuracy to predict interstitial lung disease. In particular, anticentromere antibodies or limited cutaneous subset of systemic sclerosis patients with thoracic lymphadenopathy showed earlier interstitial lung disease onset than those without lymphadenopathy. In addition, patients who developed interstitial lung disease had higher frequency of anti-Scl-70 (57% vs 19%; p = 0.009) and diffuse cutaneous subset (29% vs 3%; p = 0.02) than those who did not.

Conclusions:

Thoracic lymphadenopathy was the strongest independent predictor of systemic sclerosis-interstitial lung disease, mostly in anticentromere antibodies and limited cutaneous subset of systemic sclerosis patients. Further prospective studies are needed to confirm our preliminary data and to understand whether thoracic lymphadenopathies may have a pathogenetic role in interstitial lung disease development.

Prognosticating Outcomes in Interstitial Lung Disease by Mediastinal Lymph Node Assessment. An Observational Cohort Study with Independent Validation

RATIONALE

Mediastinal lymph node (MLN) enlargement on chest computed tomography (CT) is prevalent in patients with interstitial lung disease (ILD) and may reflect immunologic activation and subsequent cytokine-mediated immune cell trafficking.

OBJECTIVES

We aimed to determine whether MLN enlargement on chest CT predicts clinical outcomes and circulating cytokine levels in ILD.

METHODS

MLN measurements were obtained from chest CT scans of patients with ILD at baseline evaluation over a 10-year period. Patients with sarcoidosis and drug toxicity-related ILD were excluded. MLN diameter and location were assessed. Plasma cytokine levels were analyzed in a subset of patients. The primary outcome was transplant-free survival (TFS). Secondary outcomes included all-cause and respiratory hospitalizations, lung function, and plasma cytokine concentrations. Cox regression was used to assess mortality risk. Outcomes were assessed in three independent ILD cohorts.

MEASUREMENTS AND MAIN RESULTS

Chest CT scans were assessed in 1,094 patients (mean age, 64 yr; 52% male). MLN enlargement (≥10 mm) was present in 66% (n = 726) and strongly predicted TFS (hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.12-2.10; P = 0.008) and risk of all-cause and respiratory hospitalizations (internal rate of return [IRR], 1.52; 95% CI, 1.17-1.98; P = 0.002; and IRR, 1.71; 95% CI, 1.15-2.53; P = 0.008, respectively) when compared with subjects with MLN <10 mm. Patients with MLN enlargement had lower lung function and decreased plasma concentrations of soluble CD40L (376 pg/ml vs. 505 pg/ml, P = 0.001) compared with those without MLN enlargement. Plasma IL-10 concentration >45 pg/ml predicted mortality (HR, 4.21; 95% CI, 1.21-14.68; P = 0.024). Independent analysis of external datasets confirmed these findings.

CONCLUSIONS

MLN enlargement predicts TFS and hospitalization risk in ILD and is associated with decreased levels of a key circulating cytokine, soluble CD40L. Incorporating MLN and cytokine findings into current prediction models might improve ILD prognostication.

Abdominal Pain and Intermittent Fevers in a 16-Year-Old Girl

A 16-year-old girl presented to the emergency department with intermittent fevers and worsening abdominal pain of 5 weeks duration. She had a history of travel to a less developed country and exposure to possible infectious diseases. Abdominal imaging and blood tests revealed diffuse mesenteric lymphadenopathy, elevated transaminases, and elevation of inflammatory markers. Gastroesophageal and colon endoscopies revealed gastric ulcers, and the patient was discharged with a presumptive diagnosis of systemic juvenile idiopathic arthritis given the lymphadenopathy seen on imaging, serositis, sacroiliac joint stiffness noted on physical examination, and pain relief with celecoxib. She presented again 4 days later with worsening abdominal tenderness, elevated transaminases, and new-onset abdominal distention. Tissue biopsy yielded the diagnosis and directed appropriate treatment.

Sentinel Lymph Node Characterization with a Dual-Targeted Molecular Ultrasound Contrast Agent

PURPOSE

The purpose of this study was to assess the performance of molecular ultrasound with dual-targeted microbubbles to detect metastatic disease in the sentinel lymph nodes (SLNs) in swine model of naturally occurring melanoma. The SLN is the first lymph node in the lymphatic chain draining primary tumor, and early detection of metastatic SLN involvement is critical in the appropriate management of melanoma.

PROCEDURE

Nine Sinclair swine (weight 3-7 kg; Sinclair BioResources, Columbia, MO, USA) with naturally occurring melanoma were examined. Siemens S3000 scanner with a 9L4 probe was used for imaging (Siemens Healthineers, Mountain View, CA). Dual-targeted contrast agent was created using Targestar SA microbubbles (Targeson, San Diego, CA, USA) labeled with α_νβ₃-integrin and P-selectin antibodies. Targestar SA microbubbles labeled with IgG-labeled were used as control. First, peritumoral injection of Sonazoid contrast agent (GE Healthcare, Oslo, Norway) was performed to detect SLNs. After that, dual-targeted and IGG control Targestar SA microbubbles were injected intravenously with a 30-min interval between injections. Labeled Targestar SA microbubbles were allowed to circulate for 4 min to enable binding. After that, two sets of image clips were acquired several seconds before and after a high-power destruction sequence. The mean intensity difference pre- to post-bubble destruction within the region of interest placed over SLN was calculated as a relative measure of targeted microbubble contrast agent retention. This process was repeated for non-SLNs as controls. All lymph nodes evaluated on imaging were surgically removed and histologically examined for presence of metastatic involvement.

RESULTS

A total of 43 lymph nodes (25 SLNs and 18 non-SLNs) were included in the analysis with 18 SLNs demonstrating metastatic involvement greater than 5 % on histology. All non-SLNs were benign. The mean intensity (± SD) of the dual-targeted microbubbles for metastatic SLNs was significantly higher than that of benign LNs (18.05 ± 19.11 vs. 3.30 ± 6.65 AU; p = 0.0008), while IgG-labeled control microbubbles demonstrated no difference in retained contrast intensity between metastatic and benign lymph nodes (0.39 ± 1.14 vs. 0.03 ± 0.24 AU; p = 0.14).

CONCLUSIONS

The results indicate that dual-targeted microbubbles labeled with P-selectin and α_νβ₃-integrin antibodies may aid in detecting metastatic involvement in SLNs of melanoma.

Key diagnostic features of fever of unknown origin: Medical history and physical findings

Background

Fever of unknown origin (FUO) has many possible causes, so detailed history taking and physical examination are required. We identified key diagnostic features of medical history and physical findings for an efficient diagnosis of FUO.

Methods

A total of 42 consecutive patients (mean age: 50.6±20.3 years) with classic FUO were retrospectively recruited from January 2010 to March 2012. Key diagnostic features were identified from among diagnostic criteria for underlying diseases, indicators for diagnostic tests, and more useful factors for differential diagnosis.

Results

The mean number of abnormal findings per patient was 5.8 from taking the history and 2.0 from performing physical examination. In addition, the mean number of key diagnostic features identified was 0.7 (14.0%) from history taking and 0.6 (35.0%) from physical examination. The most relevant key diagnostic feature was arthritis, followed by cervical lymphadenopathy, dyspnea (with hypoxia), and ocular symptoms.

Conclusion

The usefulness of certain features of medical history and physical findings for diagnosing FUO was determined. Focusing on arthritis, cervical lymphadenopathy, dyspnea with hypoxia, and ocular symptoms might improve diagnostic efficiency in patients with FUO.

SLE and Non-Hodgkin's Lymphoma: A Case Series and Review of the Literature

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder punctuated by varied multiorgan complications all along the course of its natural history. Lymphoma represents a relatively well-recognized malignant phenomenon associated with lupus. The cause and effect relationships of lymphoma in SLE have been subject to extensive scrutiny with several studies reporting on clinic-pathologic characteristics and risk factors predicting lymphoma development in SLE. However, the pathogenic role of immunosuppressives in SLE-related lymphoma still remains unclear, and indices to help guide diagnosis, prognostication, therapy, and posttreatment monitoring are yet to be established. In this review, we describe 3 SLE patients who developed non-Hodgkin's lymphoma at different time points of their disease. Through a careful dissection of the aforementioned cases, we intend to apprise readers of the currently available literature surrounding risk factors, management, and prognosis in SLE-related lymphoma. We will also review and discuss the implications of immunosuppressives in SLE-related lymphoma and the role of mycophenolate mofetil in SLE-related primary CNS lymphoma development.

An atypical case of late-onset systemic lupus erythematosus with systemic lymphadenopathy and severe autoimmune thrombocytopenia/neutropenia mimicking malignant lymphoma

Here, we report a rare case of systemic lupus erythematosus (SLE) with conspicuous manifestation of hematological abnormalities. At onset, the 52-year-old male patient showed systemic lymphadenopathy and splenomegaly, severe autoimmune thrombocytopenia, and autoimmune neutropenia. Bone marrow examination and lymph node biopsy excluded the possibility of malignant lymphoma. Based on laboratory findings, he was finally diagnosed with combined autoimmune cytopenia coupled with SLE. Atypical clinical manifestations of SLE prompted us to explore the possibility of autoimmune lymphoproliferative syndrome (ALPS). However, we did not detect an increased number of CD4^-/CD8^-, CD3⁺, TCRαβ⁺ double-negative T cells in the circulating blood or dysfunctional T cell apoptosis in the Fas/Fas ligand pathway due to mutations in the FAS, FASLG or CASP10 genes. Combined autoimmune cytopenia is a rare clinical entity that in some cases co-occurs with other autoimmune diseases. Given that most SLE patients presenting atypical hematological manifestations at an early stage subsequently exhibit typical systemic manifestations, the present case raises the possibility that initial hematological abnormalities may be signs of unexpected SLE manifestations.

Rosai-Dorfman Disease of the Gastrointestinal Tract: Report of a Case and Review of the Literature

Rosai-Dorfman disease (RDD) is a rare, acquired disease of unknown etiology that affects primarily children and young adults. It is characterized by a proliferation of distinctive histiocytes in the lymph nodes and/or extranodal sites. Involvement of the gastrointestinal tract is rare. We report a case of RDD in a 60-year-old woman who presented with hematochezia and was found to have RDD of the rectum presenting as a rectal mass. This report highlights the current pathogenetic mechanisms, immunohistochemical markers, and the gastrointestinal manifestations of RDD.

Progressive Transformation of Germinal Centers: Single-Center Experience of 33 Turkish Patients

Progressive transformation of germinal centers (PTGCs) is a benign disease of the lymph nodes that is rarely associated with Hodgkin disease. We reviewed the clinical and pathologic features of PTGCs and the relationship of PTGCs with lymphoid neoplasia in an adult population. The data from 33 patients who were diagnosed with PTCGs were retrospectively analyzed. Of the 33 PTGC patients, 48.5% were men and 51.5% were women, with a mean age of 43.8 years at diagnosis. Most of the enlarged and excised lymph nodes were cervical and axillary. Diffuse large B-cell lymphoma and nodular lymphocyte predominant Hodgkin lymphoma was detected concurrent with PTGC in 2 patients. Also, PTGCs was detected 3 years after the diagnosis of diffuse large B-cell lymphoma, nodular lymphocyte predominant Hodgkin lymphoma, and T-cell-rich B-cell lymphoma in 3 patients. No relapse was found in the patients with lymphoma, and no progression to lymphoma was detected during the follow-up of the other patients. PTGCs is not considered a premalignant entity; however, the development of lymphoma has been reported rarely. If PTGCs occurs in the follow-up process of patients with lymphoma, the follow-up intervals should be shortened.

Thoracic lymphadenopathy in benign diseases: A state of the art review

Lymphadenopathy is a common radiological finding in many thoracic diseases and may be caused by a variety of infectious, inflammatory, and neoplastic conditions. This review aims to describe the patterns of mediastinal and hilar lymphadenopathy found in benign diseases in immunocompetent patients. Computed tomography is the method of choice for the evaluation of lymphadenopathy, as it is able to demonstrate increased size of individual nodes, abnormalities of the interface between the mediastinum and lung, invasion of surrounding fat, coalescence of adjacent nodes, obliteration of the mediastinal fat, and hypo- and hyperdensity in lymph nodes. Intravenous contrast enhancement may be needed to help distinguish nodes from vessels. The most frequent infections resulting in this finding are tuberculosis and fungal disease (particularly histoplasmosis and coccidioidomycosis). Sarcoidosis is a relatively frequent cause of lymphadenopathy in young adults, and can be distinguished from other diseases - especially when enlarged lymph nodes are found to be multiple and symmetrical. Other conditions discussed in this review are silicosis, drug reactions, amyloidosis, heart failure, Castleman's disease, viral infections, and chronic obstructive pulmonary disease.

Cervical: Lymphadenopathy

The neck region contains around 300 lymph nodes (LNs) out of 800 LNs in the whole body. The detailed study of LNs by Rouviere in 1932 [1] and the later illustration of metastatic predilection of head and neck malignancies to certain LN regions by Lindberg et al. [2] paved the road to a clinically sound classification. The American Academy of Otolaryngology and Head and Neck Surgery (AAO-HNS) and the American Joint Committee on Cancer (AJCC) developed the currently widely accepted levels classification of the cervical LNs (Table 8.1, Figs. 8.1 and 8.2).

Chronic and recurrent benign lymphadenopathy without constitutional symptoms associated with human herpesvirus-6B reactivation

Chronic/recurrent behaviour may be encountered in some distinct atypical or malignant lymphoproliferations, while recurrences are not generally observed in reactive/benign lymphadenopathies. We retrospectively analysed a consecutive series of 486 human immunodeficiency virus-negative adults, who underwent lymphadenectomy. Neoplastic and benign/reactive histopathological pictures were documented in 299 (61·5%) and 187 (38·5%) cases, respectively. Of note, seven of the 111 (6·3%) patients with benign lymphadenopathy without well-defined aetiology, showed chronic/recurrent behaviour, without constitutional symptoms. Enlarged lymph nodes were round in shape and hypoechoic, mimicking lymphoma. Reactive follicular hyperplasia and paracortical expansion were observed. Human herpesvirus (HHV)-6B positive staining in follicular dendritic cells (FDCs) was documented in all seven patients. Serological, molecular and immunological examinations suggested HHV-6B reactivation. Among the remaining 104 cases with reactive lymphoid hyperplasia in the absence of well-known aetiology and without recurrences, positivity for HHV-6B on FDCs was found in three cases, whereas in seven further patients, a scanty positivity was documented in rare, scattered cells in inter-follicular regions. Immunohistochemistry for HHV-6A and HHV-6B was invariably negative on 134 lymph nodes, with either benign pictures with known aetiology or malignant lymphoproliferative disorders, tested as further controls. Future studies are warranted to investigate a potential association between HHV-6B reactivation and chronic/recurrent benign lymphadenopathy.

Frequency and Risk Factors for Associated Lymphomas in Patients With Lymphomatoid Papulosis

BACKGROUND

Lymphomatoid papulosis (LyP) is classified as an indolent cutaneous lymphoma, but outcome dramatically worsens if LyP is associated with lymphoma. The frequency of this association remains unclear in the literature. Here, we assess the frequency and risk factors of association between LyP and another lymphoma in an 11-year retrospective study conducted in 8 dermatology departments belonging to the French Study Group on Cutaneous Lymphoma (FSGCL).

PATIENTS AND METHODS

Patients with LyP were identified and data extracted from the FSGCL registry between 1991 and 2006. Patients were followed up to January 2014. Age, sex, number of skin lesions, histologic subtype, and genotype were recorded at baseline. Risk factors were determined using univariate and multivariate analysis. Cumulative probability of association was calculated using the Kaplan-Meier method.

RESULTS

We observed 52 cases of lymphomas (cutaneous, n = 38; systemic, n = 14) in 44 of 106 patients (41%). Lymphoma diagnosis was concomitant with or prior to LyP diagnosis in 31 cases and occurred during the course of LyP in 21 cases (cutaneous, n = 14; systemic, n = 7; median delay: 5 years; interquartile range: 1.5-7 years). In multivariate analysis, main prognostic factors for association between LyP and another lymphoma were older age (odds ratio [OR]: 1.05 per year; 95% confidence interval [CI]: 1.01-1.08; p = .011) and presence of a T-cell clone in LyP lesions (OR: 7.55; 95% CI: 2.18-26.18; p = .001).

CONCLUSION

Older age and presence of a T-cell clone in LyP lesions are risk factors for associated lymphomas in patients with LyP. These findings should help to identify patients who require close management in clinical practice.

IMPLICATIONS FOR PRACTICE

The management of lymphomatoid papulosis (LyP) is that of an indolent cutaneous lymphoma, based on its excellent prognosis. However, this good prognosis is altered if LyP is associated with lymphoma. Furthermore, risk factors for and frequency of this association remain unclear in the literature. The results presented here demonstrate a high rate of association between LyP and other lymphomas (41%) as well as a long median delay of occurrence (5 years), which emphasizes the need for prolonged follow-up of patients with LyP. Moreover, two main risk factors (i.e., older age and presence of a T-cell clone in LyP lesions) are highlighted, which should help clinical practitioners to identify patients who require close management.

A Novel and Likely Inherited Lymphoproliferative Disease in British Shorthair Kittens

An unusual lymphoproliferative disease was identified in multiple closely related British Shorthair (BSH) kittens, suggesting an inherited predisposition to disease. Affected kittens typically developed rapidly progressive and marked generalized lymphadenopathy, moderate splenomegaly, and regenerative and likely hemolytic anemia from 6 weeks of age. Microscopic findings were suggestive of multicentric T-cell lymphoma, but additional testing revealed a polyclonal population of CD3+/CD4–/CD8– “double negative” T cells (DNT cells). This is a novel disease presentation with similarities to the human disorder autoimmune lymphoproliferative syndrome (ALPS), a rare inherited disease causing lymphoproliferation and variable manifestations of autoimmunity. The human disease is most commonly due to the presence of Fas gene mutations causing defective lymphocyte apoptosis, and further investigations of both the mode of inheritance and genetic basis for disease in affected cats are currently in progress.

Unicentric Castleman's disease presenting as a pulmonary mass: a diagnostic dilemma

Patient: Female, 16

Final Diagnosis: Castleman’s Disease

Symptoms: Chest pain • cough non-productive

Medication: —

Clinical Procedure: —

Specialty: Oncology

Potential role of (18)F-2-fluoro-2-deoxy-glucose positron emission tomography/computed tomography imaging in patients presenting with generalized lymphadenopathy

Generalized lymphadenopathy is a common and often vexing clinical problem caused by various inflammatory, infective and malignant diseases. We aimed to review briefly and highlight the potential role of ¹⁸F-2-fluoro-2-deoxy-glucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) in such patients. ¹⁸F-FDG PET/CT can play an important role in the management of generalized lymphadenopathy. It can help in making an etiological diagnosis; can detect extranodal sites of involvement and employed for monitoring response to therapy.

Secondary syphilis presenting as a generalized lymphadenopathy: clinical mimicry of malignant lymphoma

The diagnosis of syphilis remains challenging. The absence of classical features of the disease, such as the rash of secondary syphilis or genital lesion, may pose diagnostic difficulties. In this article, we report a case of secondary syphilis in which the clinical syndrome and pattern of fluorodeoxyglucose uptake mimicked malignant lymphoma. This case highlights the importance of thorough history taking including sexual contact. Clinicians should be alert for syphilis-underlying unexplained lymphadenopathy, even in the absence of typical rash or genital lesion.

Surgically curable non-iron deficiency microcytic anemia: Castleman's disease

BACKGROUND

Castleman's disease (CD) is a rare, benign lymphoproliferative disorder that can involve single lymph node stations or can be systemic. Unicentric CD in patients with microcytic anemia is rarely described in the English literature.

CASE REPORT

We describe the case of a 19-year-old Chinese woman with hyaline vascular type of unicentric CD presenting as severe non-iron deficiency microcytic anemia. We report the clinical course from the initial presentation to diagnosis and surgical cure, and discuss the most up-to-date information on CD.

CONCLUSIONS

CD should be included in the differential diagnosis of microcytic anemia. Imaging tools and pathological studies should be considered in order to make a more accurate diagnosis and to avoid the use of ineffective treatments.

Lymphomatoid papulosis followed by anaplastic large cell lymphoma in a pediatric patient

Lymphomatoid papulosis (LyP) is a benign, self-healing, papular eruption that can wax and wane over time. Transformation to T-cell lymphoma has been well documented in 10% to 20% of adults with LyP. However, this transformation rarely occurs in patients younger than 20 years of age. Here, we present the first known pediatric patient in Korea, a 12-year-old boy who developed a subcutaneous nodule on the scrotum 13 months after papulonecrotic lesions of LyP were identified on both lower extremities and face. Histological and immunohistochemical examination of the subcutaneous nodule revealed anaplastic large cell lymphoma (ALCL). A T-cell receptor gene rearrangement analysis demonstrated an identical rearranged pattern in the two specimens, indicating that a common T-cell clone had proliferated over time in both the LyP and ALCL lesions.

Genetic defects of apoptosis and primary immunodeficiency

Programmed cell death is important for maintaining lymphocyte homeostasis. Several human-inherited diseases with impaired apoptosis have been identified at the genetic level: autoimmune lymphoproliferative syndrome, caspase-8 deficiency state, and X-linked lymphoproliferative syndrome. These diseases feature excess lymphocyte accumulation, autoimmunity, or immunodeficiency. Elucidating their molecular pathogenesis has also provided new insights into the signaling mechanisms regulating apoptosis and lymphocyte activation.

Lymphomes T angio-immunoblastiques

Angioimmunoblastic T-cell lymphoma most often affects the elderly. Patients present with generalized lymphadenopathy and systemic symptoms; half also have hepatomegaly, splenomegaly and a rash. Polyclonal hypergammaglobulinemia, elevated lactate dehydrogenase, and anemia are the main laboratory abnormalities. Autoimmune phenomena (including autoimmune hemolytic anemia, immunologic thrombocytopenia, and autoantibodies) are common. Lymph node biopsy is needed to confirm this diagnosis. Genetic analysis that reveals a monoclonal T-cell population is also relevant. The underlying immune deficiency explains the frequency of infections. Most patients are treated with combination chemotherapy. Autologous stem cell transplantation is proposed to the youngest. Immunosuppressive drugs may be appropriate for elderly or relapsing patients. The overall 5-year survival rate is 30%.

Kikuchi Disease Mimicking Malignant Lymphoma on FDG PET/CT

A 10-year-old girl presented with a 2-month history of intermittent fever and palpable masses in the right side of the neck. Whole body FDG PET/CT imaging was performed, showing multiple FDG-avid nodular masses in cervical and abdominal lymph nodes. The patient then underwent excision biopsy of the enlarged right cervical nymph nodes, which confirmed the diagnosis of Kikuchi disease. After steroid therapy, fever and cervical lymphadenopathy subsided. After 3 months, follow up FDG PET/CT was done, and there was no abnormality. Kikuchi disease could lead to the wrong initial diagnosis of tuberculosis or even malignant lymphoma.

Angioimmunoblastic T-cell lymphoma: clinical and laboratory features at diagnosis in 77 patients

We retrospectively analyzed 77 patients with pathologically diagnosed angioimmunoblastic T-cell lymphoma from a single city. There were 43 men and 34 women; the median age was 64.5 years (range, 30-91 yr). Average time between first symptoms of the disease and diagnosis was 3.6 months. At diagnosis, peripheral nodes were present in all but 1 patient, and were generalized in 90% of cases. Constitutional symptoms were reported in 77% of cases and spleen enlargement in 51%. A cutaneous eruption--morbilliform, urticarial, or more polymorphic--was present in 45% of patients; in one-third of them, the eruption occurred after drug administration. Other clinical manifestations included pleuritis (22%); arthralgia or arthritis (17%); ear, nose, and throat involvement (14%); central or peripheral neurologic manifestations (10%); and ascites (5%). Most patients presented with advanced disease at diagnosis (bone marrow involvement in 60% of cases). The main laboratory abnormalities were elevated lactate dehydrogenase levels (71%), inflammatory syndrome (67%), hypergammaglobulinemia (50%), anemia (51%), and lymphopenia (52%). Auto- or disimmune manifestations were reported in one-third of patients: autoimmune hemolytic anemia was present at diagnosis in 19% of patients and thrombocytopenic purpura in 7%. Documented vasculitis was described in 12% of cases. Clonality was analyzed in lymph nodes in 47 patients: T-cell and B-cell clones were found in 45 (96%) and 20 (45%) patients, respectively. Chromosomal abnormalities were identified in 62% of cases: trisomies 3, 5, 18, 19, additional X chromosome, and deletion of chromosome 7 were the most common abnormalities. The current study underlines the diversity of presenting manifestations of angioimmunoblastic T-cell lymphoma.

Non-Hodgkin's lymphoma mimicking gynecological malignancies of the vagina and cervix: a report of four cases

Although in the past two decades there has been a sharp rise in the incidence of extranodal primary lymphomas in the United States, non-Hodgkin's lymphoma (NHL) of the female genital tract is still rare. We present four cases of extranodal NHL presenting with signs and symptoms consistent with cancer of the vagina or cervix and lacking the “B” symptoms often associated with systemic lymphoma such as fever, weight loss, night sweat, and fatigue. It is important for gynecologists to be aware of this neoplastic disease and to include cervical or vaginal lymphoma in the differential diagnosis of patients presenting with examinations suggestive of cervical or vaginal cancer. A correct diagnosis leads to the appropriate therapy, and radical gynecological surgery can be avoided for primary cervical and vaginal lymphoma

Uncommon lymphadenopathies of immunopathogenesis can be misinterpreted as malignant diseases

Lymphadenomegaly is a common sign of benign and malignant disorders. In our practice, only every fifth patient is found to have primary or secondary nodal malignancy. Benign disorders, including banal infections and other non-neoplastic conditions, however, cause most of the cases. Among these, there are some rare entities, resulting in persistent lymphadenopathy that may cause differential diagnostic problems in the daily practice. We report here three patients, having Rosai-Dorfman disease, multicentric Castleman's disease and Kikuchi's lymphadenitis, who exemplify such cases. Our purpose with this presentation is to emphasise importance of vigorous co-operation between clinicians and pathologists. In general, it is imperative to prefer specialised haematopathological laboratories that may facilitate proper diagnosis.

Paraneoplastic syndromes of the peripheral nerves

PURPOSE OF REVIEW

To describe the paraneoplastic disorders of the motor and sensory nerves and neurons, and their immunologic associations.

RECENT FINDINGS

Recently proposed diagnostic criteria for paraneoplastic disorders may assist in determining the likelihood a given neuropathy or neuronopathy is related to an underlying malignancy. Of this group of disorders, paraneoplastic sensory neuronopathies are the most frequent; many of these patients have anti-Hu antibodies and small-cell lung cancer. There is often motor, autonomic, or central nervous system involvement, and electrophysiological studies may demonstrate not only sensory changes, but also motor abnormalities. While cancer has been found more frequently than expected in patients with Guillain-Barré syndrome, this association is extremely rare. A limited number of reports have described chronic inflammatory demyelinating polyradiculoneuropathy, multifocal motor neuropathy with conduction block, vasculitic neuropathies, and motor neuron disease as paraneoplastic disorders. Anti-CV2 antibodies are frequently associated with a paraneoplastic sensorimotor axonal neuropathy and small-cell lung cancer. Peripheral nerve hyperexcitability may occur with or without a cancer association, and in both instances patients often have antibodies to voltage-gated potassium channels; thymoma and small-cell lung cancer are the most common underlying tumors. Plasma cell proliferative disorders are frequently associated with neuropathies, particularly demyelinating ones.

SUMMARY

There is increasing recognition of an extensive variety of paraneoplastic disorders of the peripheral nerves. In many of these disorders onconeuronal antibodies are absent. Whole body fluorodeoxyglucose positron emission tomography scanning helps uncover the associated tumor, and recently proposed criteria may assist in the diagnosis. In many instances, prompt treatment of the tumor and immunotherapy result in symptom stabilization or neurologic improvement.