A 44-year-old male from Salta Capital, Argentina, a high school teacher with a history of mild intermittent asthma.
It began two months before the referral with asthenia, adynamia, involuntary weight loss associated with daily febrile records predominantly nocturnal accompanied by sweating.
One month prior to admission to the hospital he was admitted to the province of Salta where numerous studies were conducted.
Analyses showed a erythrocyte sedimentation rate (ESR) 60 mm in the first hour with a normal platelet count (MCV) < 20, C-reactive protein (CRP) 4.8 mg/ dl (white blood cell count)
Rest was normal including urine sediment.
All serological markers were negative including hepatitis A virus, hepatitis B, hepatitis C, cytomegalovirus, Epstein, human immunodeficiency virus.
Other markers such as VDRL, Huddleson's reaction, thick blood smear, and the Widal test were negative.
PPD was negative.
Three pairs of blood cultures were negative for common germs and brucellosis.
The direct and indirect Coombs test was negative.
Abdominal, prostatic and testicular ultrasound showed hepatic steatosis, and the rest without any particularities.
A nuclear magnetic resonance cholangiography was normal.
Doppler ultrasound showed no vegetations.
A computed axial tomography (CAT) of the brain, thorax, abdomen and pelvis with oral and intravenous contrast showed significant subcutaneous edema of the generalized abdominal wall, and the rest without particularities.
High and low endemic pathologies were performed.
Bone marrow aspiration showed normal cellularity and negative cultures.
Given the alteration of liver tests liver biopsy and cholecystectomy were performed whose pathology reported mild focal hepatitis, nonspecific focal steatosis and chronic nonspecific stenosis.
Due to the persistence of febrile records without a clear etiology, two months after the onset of symptoms, she was admitted to our institution.
Upon admission, the patient was persistently febrile, and the only finding on physical examination was indurated edema in the abdominal region and erythema multiforme.
Cultures, serology and CT scans were repeated without new findings.
Puncture of the abdominal wall soft tissues was performed in the erythema area where multisensitive Streptococcus was rescued, so he received amoxicillin treatment for one week without showing clinical change.
A nasogastric tube was installed for feeding and transfusional support was performed.
The patient remained febrile so a skin and subcutaneous cellular tissue biopsy was taken.
This patient reported hypodermis with vascular structures compatible with presence of large cell lumens with intravascular nucleoside analogues CD 45+, CD 68-, CD 20+ 79, PAX 5+, CDP
Magnetic resonance imaging (MRI) of the brain with gadolinium showed no abnormalities.
She started treatment with rituximab, cyclophosphamide, adriamycin, vincristine and prednisone (R-CHOP) every 21 days for 6 applications.
The patient had a good evolution, without fever, decreased abdominal edema and clear improvement in general condition.
Autologous hematopoietic stem cell transplantation (ABMT) was performed as consolidation of the first complete remission and has been free of disease for two years.
