Get Permission Devraj, Kappagantu, Dugad, Shinde, and Shah: An aberrant presentation of non-hodgkin’s lymphoma as pus: A curious journey


Introduction

Lymphoblastic lymphoma (LBL) is the most aggressive kind of non-lymphoma Hodgkin's (NHL), accounting for about 2% of all adult NHL cases.1 T-lymphoblastic lymphoma (T-LBL) is an uncommon cancer that affects children and teenagers.2 Large anterior mediastinal mass, pleural effusion, superior vena cava syndrome, airway obstruction, and pericardial effusion are typical symptoms, as are B symptoms and high serum lactate dehydrogenase (LDH), with liver and spleen involvement being less prevalent.3 The response rate to chemotherapy is very good although relapse is common with poor survival rates.4, 5

Case Report

A 25 years old female presented to emergency department of a tertiary care centre (Medical college & Hospital) with chest tube in left haemothorax in situ. She complained of chest pain in the last 6 weeks, dyspnoea and facial puffiness in the last 15 days. She also had history of weight loss in past 2 months. She had earlier history of pulmonary tuberculosis 3 years back and took anti tubercular treatment for 6 months. She was admitted at private hospital where thoracocentesis was done and later chest tube was inserted for recurrent pleural effusion which was exudative in nature.

On general examination we found left supraclavicular lymphadenopathy of size 2 × 1.5cm and grade 2 clubbing.

On Systemic examination dull note with reduced TVF was found in left Hemothorax. Breath sounds were reduced on left side.

Figure 1

Chest X ray showing left side ICD in situ and pleural effusion

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/3be0e1f7-9f63-4dc8-9eea-d9c9780eb97aimage1.jpeg
Figure 2

HRCT- s/o bilateral pleural effusion, airway compression and mediastinal lymphadenopathy

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/3be0e1f7-9f63-4dc8-9eea-d9c9780eb97aimage2.png

    

Figure 3

Histopathological findings

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/15262f13-7b62-447c-8e27-7fb3a7786eaa/image/80c7ffd8-ec87-40c3-8296-dbaa1fc2d706-uimage.png

The pleural fluid was sent for analysis. It was reported as exudative pleural effusion with low ADA and negative for malignant cells. Pleural fluid proteins – 2.1gm/dl, sugars – 50 gm/dl. Pleural fluid lymphocytes – 78%, polymorphs – 22%.

Fine needle aspiration cytology of lymph node was reported as atypical lymphoproliferative disorder. Further lymph node biopsy was sent for histopathological examination, mycobacterial culture and GeneXpert for tuberculosis. Histopathology (Figure 3) was suggestive of T lymphoblastic lymphoma. One of the lymph node was pus filled, hence was drained. Pus was reported as sterile for AFB smear, gram stain and culture sensitivity. Patient received single cycle of CHOP regimen chemotherapy.

Discussion

NHL is a heterogeneous group of cancers that emerge from two separate lymphocyte types, B and T lymphocytes, at different phases of differentiation.6 these types of lymphoid neoplasms have been grouped together by the World Health Organization as precursor T-cell or B-cell lymphoblastic leukaemia/lymphoma. However, several recent investigations have revealed that T-LBL and T-ALL have different molecular profiles.7, 8, 9, 6 and T- LBL's response to therapy appears to be different from T- ALL's.7

In our case, before referral to our institute the past history of pulmonary tuberculosis could have suggested reactivation of the disease along with non-availability of thorough analysis of pleural fluid and no suspicion of malignancy lead to loss of time. In comparison with didn’t found similar cases which were presenting with pus in lymphnode although the presentation were similar in respect to age group, gender and symptoms.

In clinical examination we found left cervical lymphadenopathy and it raised suspicion and through workup was done and it turned out to be malignancy.

In relation to our case; earlier history of tuberculosis, pus from lymph node could mislead to infective aetiology; as lymph node necrosis is commonly found in Hodgkin’s disease.

This fact reiterates the fact that through clinical examination and history leads to proper diagnosis and management of the patient and can save time of the patients.

Conflicts of Interest

None.

Source of Funding

None.

Acknowledgements

We acknowlodege department of pathology for providing histopathological images.

References

1 

A clinical evaluation of the International Lymphoma Study Group classification of non-Hodgkin’s lymphoma The Non-Hodgkin’s Lymphoma Classification ProjectBlood19978911390918

2 

R Bassan E Maino S Cortelazzo Lymphoblastic lymphoma: an updated review on biology, diagnosis, and treatmentEur J Haematol201696544760

3 

G Borthakur SM O’brien A Younes B Coiffier Lymphoblastic LymphomaLymphoma: Diagnosis and TreatmentHumana PressTotowa, NJ201333043

4 

CA Portell JW Sweetenham Adult lymphoblastic lymphomaCancer J20121854328

5 

IH Ryu IS Cho AJ Ryu MG Kim JW Jeon JS Kim Long-Term Survival after T-cell Lymphoblastic Lymphoma Treated with One Cycle of Hyper-CVAD RegimenCancer Res Treat20154711159

6 

S Cortelazzo M Ponzoni A J Ferreri D Hoelzer Lymphoblastic lymphomaCrit Rev Oncol Hematol201179333043

7 

EA Raetz SL Perkins D Bhojwani K Smock M Philip WL Carroll Gene expression profiling reveals intrinsic differences between T-cell acute lymphoblastic leukemia and T-cell lymphoblastic lymphomaPediatr Blood Cancer200647213040

8 

A Uyttebroeck S Suciu G Laureys A Robert H Pacquement A Ferster Treatment of childhood T-cell lymphoblastic lymphoma according to the strategy for acute lymphoblastic leukaemia, without radiotherapy: long term results of the EORTC CLG 58881 trialEur J Cancer20084468406

9 

E Jabbour S Koscielny C Sebban N Peslin C Patte T Gargi High survival rate with the LMT-89 regimen in lymphoblastic lymphoma (LL), but not in T-cell acute lymphoblastic leukemia (T-ALL)Leukemia20062058149



jats-html.xsl


This is an Open Access (OA) journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

  • Article highlights
  • Article tables
  • Article images

Article History

Received : 18-08-2022

Accepted : 15-10-2022


View Article

PDF File   Full Text Article


Copyright permission

Get article permission for commercial use

Downlaod

PDF File   XML File   ePub File


Digital Object Identifier (DOI)

Article DOI

https://doi.org/ 10.18231/j.ijirm.2022.039


Article Metrics






Article Access statistics

Viewed: 893

PDF Downloaded: 691