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P0343 KIDNEY LYMPHOMA PRESENTING AS ACUTE KIDNEY INJURY
S118
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
result. On the 10th day of the antimicrobial therapy a complete blood count demonstrated thrombocytopenia (22000/mm3 ). In previous hematologic examinations thrombocyte counts were in normal range. We started to evaluate the possible etiologies for thrombocytopenia in this patient. Thrombocytopenia didn’t recovered after discontuination of the antimicrobial therapy. Viral serology for hepatitis,HIV, TORCH and specific autoantibodies were negative. Blood film confirmed thrombocytopenia. A bone marrow biopsy showed a normocellular marrow. By exclusion a diagnosis of acute ITP was made. According to the diagnosis 1 mg/kg/day prednisolone treatment was started then dosage was decreased gradually. Thrombocytopenia respond to the steroid therapy in 2 weeks and stayed at normal limits in the next two months. But at the 3rd month control examination, asymptomatic thrombocytopenia in her complete blood count was found. We retreated the patient with the same steroid therapy but the patient did not respond to the treatment, so IVIG therapy was planned. Before applying the treatment, laboratory studies showed hypothyroidism. Because of this we first treated the hypothyroidism by L-thyroxin. After thyroid hormone replacement therapy thrombocytopenia resolved with the same dosage of prednisolone. Conclusion: This case suggests that the hypothyroidism may have resulted in the treatment refractory thrombocytopenia. With correction of her thyroid deficiency and adequate suppression of her TSH the platelet count returned to normal. According to these, the refractory statement of this patient was because of her hypothyroidism. Our case demonstrates that, a better treatment result could be achieved by treating the underlying thyroid dysfunction which possibly had made a resistant situation to the steroid therapy.
P0343 KIDNEY LYMPHOMA PRESENTING AS ACUTE KIDNEY INJURY
Arvind Ponnusamy, Jyothi Kondlapudi, Ricardo J Jose, Aladdin Shurrab. Salford Royal Foundation Trust, Salford, United Kingdom Introduction: The Kidney can be affected in chronic lymphocytic leukaemia (CLL) due to a variety of reasons. Leukaemic infiltration of the kidney is common in CLL but rarely causes acute renal failure. We report a case of a 62year old woman with CLL who presented with renal failure due to leukaemic infiltration of the kidney. Case presentation: This caucasian lady presented with a two week history of tiredness, nausea and loss of weight. Her past medical history included hypertension, hypercholesterolaemia, transient ischaemic attack and one month ago had been diagnosed with CLL Her creatinine was noted to be raised at 591mmol/l and one month previously, this had been 205mmol/l.Urinary protein quantification showed a urine protein creatinine ratio (PCR) of 75. Immunology revealed presence of raised serum free lambda chains and low levels of immunoglobulins. Renal ultrasound revealed bilateral enlarged kidneys at 12.5 cm in size with loss of corticomedullary differentiation and no evidence of hydronephrosis. CT scan showed widespread lymphadenopathy above and below the diaphragm with enlarged slightly heterogeneous kidneys. The kidney biopsy showed some sclerosed glomeruli and extensive infiltration of the interstitium by lymphocytes. This infiltrate of cells was positive for CD20, CD43, CD79a with some focal staining for CD23. This appearance was consistent with lymphomatous infiltration of the kidney in CLL. She was commenced on rasburicase and pulsed with high dose intravenous methylprednisolone which progressively improved the renal function (current creatinine 170 mmol/l) Conclusion: Leukaemic infiltration of the kidney should be considered in all patients with CLL presenting with acute renal failure because it is an indication for treatment. Treatment has shown to considerably improve renal function as demonstrated in our patient.
Materials and methods: Ninety-six patients (56 male with mean age 54±17 years) with NHL were enrolled to the study. By using Charlson concomitant disease index, concomitant disease weight incidence, concomitant state-age relationship, and probability of 10 years survey were investigated. Results: In brief history of the patients, there were some cancers in four (4%) patients (2 colon, one breast and skin cancer). The family history for cancer was detected in 16 (17%) patients (6 lung, 4 breast, 2 skin and colon, one kidney cancers and chronic lymphocytic leukemia). Mean Charlson’s concomitant disease weight index was 2.5±1 (1-6), concomitant state-age relationship was 3.7±1.7 (2-9), and probability of 10 years survey was 54±34% (0-90). Discussion: The use of Charlson’s concomitant disease index together with international prognostic markers may give more accurate information about life expectancy in NHL Moreover cancer cluster in family history of these patients was notable. Key words: Non-Hodgkin’s lymphoma, brief history, family history, life expectancy
P0345 A RARE CAUSE OF CERVICAL LYMPHADENOPATHY AND B-SYMPTOMES
Carolien Beukhof, Marjon Kerkhof, Henk Van Zaanen. Sint Franciscus Gasthuis A 25-year old Asian female presented with complaints of fatigue, eight kilograms weight loss, night sweats and enlarged, painful lymph nodes in the right cervical region since three months. On physical examination several firm, painful lymph nodes with a diameter of 1 cm werepalpable on the right side of the m. sternocleidomastoïdeus and supraclavicular. No axillary or inguinal lymph nodes were found. Additional physical examination revealed no abnormalities, especially no hepatosplenomegaly or local infections. Laboratory investigation showed erythrocyte sedimentation rate (ESR) of 7 mm/h, Hemoglobine 8,4 mmol/L, leucocytes 3,5*109 (with 46% lymphocytes and 12% monocytes), platelets 179*109, lactate dehydrogenase (LDH) 547 U/l (n <450 U/l). Ultrasonography of the cervical region revealed multiple lymph nodes predominantly at the right side. Fine needle aspiration for cytology of a lymph node was performed for diagnosis. No monoclonal B-cell population was found (normal kappa/lambda ratio). However flow cytometric evaluation showed a second T-cell population. (CD3 positive, CD5 weak positive, CD8weak positive, CD4 negative, CD7 positive, HLA-DR negative.) Because of the second T-cell population, the presence of night sweats and loss of weight and the elevated LDH value, a T-cell lymphoma could not be excluded. Therefore a surgical excision of a lymph node was performed. In addition, serology for EBV, CMV, toxoplasmosis, Yersinia, Parvovirus B19, hepatitis B and C and HIV was performed. All serology and also ANA/ENA-tests appeared to be negative. Computed tomography of the thorax and abdomen was normal. Histopathological examination of the lymph node showed a reactive lymphadenitis,with distorted architecture, diffuse expansive nodular alteration of the parenchyma with histiocytes, and apoptotic cell debris. Obvious confluent necrosis was not present. Diffuse immunohistochemical staining with CD68 and granzyme-B was seen. Since these features fit most with Kikuchi’s lymphadenitis, ‘Kikuchi-Fujimoto disease’ was diagnosed. No treatment was started and patient was seen for follow-up after 2,5 months. At that time, the symptoms as well as the lymphadenopathy were disappeared. The extensive differential diagnosis, pathogenesis and the possible relation with SLE are discussed. Conclusion: Consider Kikuchi-Fujimoto in your differential diagnoses of cervical lymfphadenopathy and B-symptomes. Keywords: Kikuchi-Fujimoto, cervical lymfphadenopathy, B-symptomes
P0346 P0344 CONCOMITAN DISEASE AND CANCER INTENSITY IN BRIEF- AND FAMILY HISTORIES IN NON-HODGKIN’S LYMPHOMA
Irfan Yavasoglu, Bilal Acar, Mustafa Unubol, Tamer Gun, Gurhan Kadikoylu, Zahit Bolaman. Adnan Menderes University Medical Faculty, Division of Hematology Introduction: Concomitant diseases in malign disorders are the most important factors affecting the prognosis and treatment. Determining of the cancer intensity in brief- and family histories of the patients may be helpful to estimate the nature of the disease. Objectives: In this study we investigated the effect of the concomitant disease on life expectancy in the patients with Non-Hodgkin’s lymphoma (NHL).
THROMBOTIC THROMBOCYTOPENIC PURPURA AS THE FIRST MANIFESTATION OF METASTATIC ADENOCARCINOMA IN A YOUNG WOMAN
Gurhan Kadikoylu 1 , Nezih Meydan 2 , Canten Tataroglu 3 , Samet Kafkas 5 , Hakan Erpek 4 , Sabri Barutca 2 , Irfan Yavasoglu 1 , Zahit Bolaman 1 . 1 Adnan Menderes University Medical Faculty, Division of Hematology, Aydin, Turkey; 2 Adnan Menderes University Medical Faculty, Division of Oncology, Aydin, Turkey; 3 Adnan Menderes University Medical Faculty, Division of Pathology, Aydin, Turkey; 4 Adnan Menderes University Medical Faculty, Division of General Surgery, Aydin, Turkey; 5 Adnan Menderes University Medical Faculty, Division of Obstetry and Gynecology, Aydin, Turkey Thrombotic thrombocytopenic purpura (TTP), a thrombotic microangiopathy,
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
result. On the 10th day of the antimicrobial therapy a complete blood count demonstrated thrombocytopenia (22000/mm3 ). In previous hematologic examinations thrombocyte counts were in normal range. We started to evaluate the possible etiologies for thrombocytopenia in this patient. Thrombocytopenia didn’t recovered after discontuination of the antimicrobial therapy. Viral serology for hepatitis,HIV, TORCH and specific autoantibodies were negative. Blood film confirmed thrombocytopenia. A bone marrow biopsy showed a normocellular marrow. By exclusion a diagnosis of acute ITP was made. According to the diagnosis 1 mg/kg/day prednisolone treatment was started then dosage was decreased gradually. Thrombocytopenia respond to the steroid therapy in 2 weeks and stayed at normal limits in the next two months. But at the 3rd month control examination, asymptomatic thrombocytopenia in her complete blood count was found. We retreated the patient with the same steroid therapy but the patient did not respond to the treatment, so IVIG therapy was planned. Before applying the treatment, laboratory studies showed hypothyroidism. Because of this we first treated the hypothyroidism by L-thyroxin. After thyroid hormone replacement therapy thrombocytopenia resolved with the same dosage of prednisolone. Conclusion: This case suggests that the hypothyroidism may have resulted in the treatment refractory thrombocytopenia. With correction of her thyroid deficiency and adequate suppression of her TSH the platelet count returned to normal. According to these, the refractory statement of this patient was because of her hypothyroidism. Our case demonstrates that, a better treatment result could be achieved by treating the underlying thyroid dysfunction which possibly had made a resistant situation to the steroid therapy.
P0343 KIDNEY LYMPHOMA PRESENTING AS ACUTE KIDNEY INJURY
Arvind Ponnusamy, Jyothi Kondlapudi, Ricardo J Jose, Aladdin Shurrab. Salford Royal Foundation Trust, Salford, United Kingdom Introduction: The Kidney can be affected in chronic lymphocytic leukaemia (CLL) due to a variety of reasons. Leukaemic infiltration of the kidney is common in CLL but rarely causes acute renal failure. We report a case of a 62year old woman with CLL who presented with renal failure due to leukaemic infiltration of the kidney. Case presentation: This caucasian lady presented with a two week history of tiredness, nausea and loss of weight. Her past medical history included hypertension, hypercholesterolaemia, transient ischaemic attack and one month ago had been diagnosed with CLL Her creatinine was noted to be raised at 591mmol/l and one month previously, this had been 205mmol/l.Urinary protein quantification showed a urine protein creatinine ratio (PCR) of 75. Immunology revealed presence of raised serum free lambda chains and low levels of immunoglobulins. Renal ultrasound revealed bilateral enlarged kidneys at 12.5 cm in size with loss of corticomedullary differentiation and no evidence of hydronephrosis. CT scan showed widespread lymphadenopathy above and below the diaphragm with enlarged slightly heterogeneous kidneys. The kidney biopsy showed some sclerosed glomeruli and extensive infiltration of the interstitium by lymphocytes. This infiltrate of cells was positive for CD20, CD43, CD79a with some focal staining for CD23. This appearance was consistent with lymphomatous infiltration of the kidney in CLL. She was commenced on rasburicase and pulsed with high dose intravenous methylprednisolone which progressively improved the renal function (current creatinine 170 mmol/l) Conclusion: Leukaemic infiltration of the kidney should be considered in all patients with CLL presenting with acute renal failure because it is an indication for treatment. Treatment has shown to considerably improve renal function as demonstrated in our patient.
Materials and methods: Ninety-six patients (56 male with mean age 54±17 years) with NHL were enrolled to the study. By using Charlson concomitant disease index, concomitant disease weight incidence, concomitant state-age relationship, and probability of 10 years survey were investigated. Results: In brief history of the patients, there were some cancers in four (4%) patients (2 colon, one breast and skin cancer). The family history for cancer was detected in 16 (17%) patients (6 lung, 4 breast, 2 skin and colon, one kidney cancers and chronic lymphocytic leukemia). Mean Charlson’s concomitant disease weight index was 2.5±1 (1-6), concomitant state-age relationship was 3.7±1.7 (2-9), and probability of 10 years survey was 54±34% (0-90). Discussion: The use of Charlson’s concomitant disease index together with international prognostic markers may give more accurate information about life expectancy in NHL Moreover cancer cluster in family history of these patients was notable. Key words: Non-Hodgkin’s lymphoma, brief history, family history, life expectancy
P0345 A RARE CAUSE OF CERVICAL LYMPHADENOPATHY AND B-SYMPTOMES
Carolien Beukhof, Marjon Kerkhof, Henk Van Zaanen. Sint Franciscus Gasthuis A 25-year old Asian female presented with complaints of fatigue, eight kilograms weight loss, night sweats and enlarged, painful lymph nodes in the right cervical region since three months. On physical examination several firm, painful lymph nodes with a diameter of 1 cm werepalpable on the right side of the m. sternocleidomastoïdeus and supraclavicular. No axillary or inguinal lymph nodes were found. Additional physical examination revealed no abnormalities, especially no hepatosplenomegaly or local infections. Laboratory investigation showed erythrocyte sedimentation rate (ESR) of 7 mm/h, Hemoglobine 8,4 mmol/L, leucocytes 3,5*109 (with 46% lymphocytes and 12% monocytes), platelets 179*109, lactate dehydrogenase (LDH) 547 U/l (n <450 U/l). Ultrasonography of the cervical region revealed multiple lymph nodes predominantly at the right side. Fine needle aspiration for cytology of a lymph node was performed for diagnosis. No monoclonal B-cell population was found (normal kappa/lambda ratio). However flow cytometric evaluation showed a second T-cell population. (CD3 positive, CD5 weak positive, CD8weak positive, CD4 negative, CD7 positive, HLA-DR negative.) Because of the second T-cell population, the presence of night sweats and loss of weight and the elevated LDH value, a T-cell lymphoma could not be excluded. Therefore a surgical excision of a lymph node was performed. In addition, serology for EBV, CMV, toxoplasmosis, Yersinia, Parvovirus B19, hepatitis B and C and HIV was performed. All serology and also ANA/ENA-tests appeared to be negative. Computed tomography of the thorax and abdomen was normal. Histopathological examination of the lymph node showed a reactive lymphadenitis,with distorted architecture, diffuse expansive nodular alteration of the parenchyma with histiocytes, and apoptotic cell debris. Obvious confluent necrosis was not present. Diffuse immunohistochemical staining with CD68 and granzyme-B was seen. Since these features fit most with Kikuchi’s lymphadenitis, ‘Kikuchi-Fujimoto disease’ was diagnosed. No treatment was started and patient was seen for follow-up after 2,5 months. At that time, the symptoms as well as the lymphadenopathy were disappeared. The extensive differential diagnosis, pathogenesis and the possible relation with SLE are discussed. Conclusion: Consider Kikuchi-Fujimoto in your differential diagnoses of cervical lymfphadenopathy and B-symptomes. Keywords: Kikuchi-Fujimoto, cervical lymfphadenopathy, B-symptomes
P0346 P0344 CONCOMITAN DISEASE AND CANCER INTENSITY IN BRIEF- AND FAMILY HISTORIES IN NON-HODGKIN’S LYMPHOMA
Irfan Yavasoglu, Bilal Acar, Mustafa Unubol, Tamer Gun, Gurhan Kadikoylu, Zahit Bolaman. Adnan Menderes University Medical Faculty, Division of Hematology Introduction: Concomitant diseases in malign disorders are the most important factors affecting the prognosis and treatment. Determining of the cancer intensity in brief- and family histories of the patients may be helpful to estimate the nature of the disease. Objectives: In this study we investigated the effect of the concomitant disease on life expectancy in the patients with Non-Hodgkin’s lymphoma (NHL).
THROMBOTIC THROMBOCYTOPENIC PURPURA AS THE FIRST MANIFESTATION OF METASTATIC ADENOCARCINOMA IN A YOUNG WOMAN
Gurhan Kadikoylu 1 , Nezih Meydan 2 , Canten Tataroglu 3 , Samet Kafkas 5 , Hakan Erpek 4 , Sabri Barutca 2 , Irfan Yavasoglu 1 , Zahit Bolaman 1 . 1 Adnan Menderes University Medical Faculty, Division of Hematology, Aydin, Turkey; 2 Adnan Menderes University Medical Faculty, Division of Oncology, Aydin, Turkey; 3 Adnan Menderes University Medical Faculty, Division of Pathology, Aydin, Turkey; 4 Adnan Menderes University Medical Faculty, Division of General Surgery, Aydin, Turkey; 5 Adnan Menderes University Medical Faculty, Division of Obstetry and Gynecology, Aydin, Turkey Thrombotic thrombocytopenic purpura (TTP), a thrombotic microangiopathy,