48-year-old Peruvian patient.
It began in September 2014 with increased cervical volume.
In February 2015 she reported general malaise, fever, night sweats and weight loss of 5 kg. In March 2015 she began with increased axillary and inguinal volume, dysphonia and dysphagia.
In addition, he presented irritative dry cough.
Finally, due to greater commitment, with a performance status of 3, she consulted in our center.
Physical examination revealed cervical lymphadenopathies of 5 cm, left supraclavicular lymph nodes of 2 cm, bilateral axillary lymph nodes of 3 cm, small inguinal and crural lymph nodes.
The hemogram showed Hb 7.5 g/dL, leukocytes 3.100 mm3 and platelets 22.000 mm3.
Peripheral blood smear (PBL) revealed large lymphoid cells, some with cleft nucleus and others with vacuum.
ESR 70 mm/h, LDH 3.524 g/L, B2 microglobulin 5.12 mg/dL, calcium 11.5 mg/dL.
HIV, HBV and HCV were negative.
Protein electrophoresis showed a small monoclonal peak in beta gamma.
IgA 77.5 (70-400 mg/dL), IgG 311.4 (700-1,600 mg/dL), IgM 42.9 (40-230 mg/dL).
Computed tomography (CT) of the neck-thorax-abdomen and pelvis showed lymphadenopathies at the level of the right neck, both primary and bilateral pleural effusion, up to 2.8 cm pre-tracheal mass, in
Axillary adenopathies up to 3.5 cm, retroperitoneal up to 3.6 cm, iliac chain up to 3 cm and inguinal 1.5 cm were performed. Myelogram showed pathological lymphocytes, similar to those observed in the periphery.
Immunophenotype by bone marrow flow cytometry (BM) showed mature pathological lymphocytes of B lineage, with intense CD45 expression, positivity for CD19, CD20, CD79a, cytoplasmic IgM
Tdt negative.
Conventional G-banding cytogenetics was performed in OM sample, showing a complex karyotype with numerical and structural alterations.
The bone marrow biopsy resulted in almost 100% of rejection.
Lymph node biopsy showed diffuse large B-cell non-Hodgkin lymphoma of germinal center origin, triple-expressor, with 100% CD10 positive, 50% MYC positive, 100% BCL-6 positive and 30% BCL2 positive.
Ki 67 of 90%.
FISH was performed with BA Vysis probe for MYC, BCL-2 and BCL-6 in a sample of formalin-fixed lymph node embedded in paraffin.
MYC analysis showed multiple patterns with 1 to 5 red signals, 1, 2 and 4 green signals and 1 to 5 fusions.
It was interpreted as positive for MYC rearrangement with amplifications of the gene.
Similar patterns were observed for BCL-2 and BCL-6, including lymphoma progressing in high grade B cells, with rearrangement of MYC, BCL-2 and BCL-6 (Triple HIT)
To molecularly rule out the t(8;14)(q34;q32) of Burkitt lymphoma (BL), FISH was performed for t(8;14)(q34;q32), resulting negative.
Prephase with corticosteroids was initiated and then chemotherapy with R-CHOP.
She had a severe adverse reaction to rituximab and was therefore suspended.
She presented consciousness compromise, so a brain CT scan showed a large brain mass with large perilesional edema.
The patient died due to poor condition and died 3 weeks after chemotherapy.
