case_images: PMC6126084_01
case_images: Gall bladder wall thickening with pericholecystic inflammatory stranding concerning for acute cholecystitis with normal pancreas.
case_images: CRIRH2018-9602373.001.jpg
case_images: PMC6126084_01_CRIRH2018-9602373.001.jpg
case_images: fig1
case_images: The CT scan of abdomen revealed intrahepatic biliary ductal dilatation and gall bladder wall thickening with pericholecystic inflammatory stranding with normal pancreas (Figure 1).
case_images: Biopsy fragment of right iliac lymph node showing sinus histiocytic aggregates interlaced with lymphocytes and plasma cells. (a) H&E stain, 100x original magnification. Small cells within the lymph nodes, showing morphologic features of plasma cells, characterized by an oval cellular morphologic, and eccentrically placed nuclei. (b) H&E stain, 200x original magnification. Majority of cellular constituents confirmed to be plasma cells, as demonstrated by diffuse reactivity for CD138 by immunohistochemistry. (c) 200x original magnification.
case_images: CRIRH2018-9602373.002.jpg
case_images: PMC6126084_01_CRIRH2018-9602373.002.jpg
case_images: fig2
case_images: CD138 (Figure 2(c)). Chromogenic in situ hybridization for kappa light chain (Figure 3(a)) and lambda light chain (Figure 3(b)) showed a mixture of kappa and lambda-bearing cells (approximate kappa to lambda ratio of 3 : 1); this finding suggested that the plasma cells were reactive in nature, arguing against the possibility of a plasma cell neoplasm.
case_images: Chromogenic in situ hybridization showing a mixture of kappa-bearing plasma (a) and lambda-bearing plasma (b) cells, with an approximate kappa to lambda ratio of 3-4 to 1, appropriate for a physiologic/reactive phenomenon, without evidence of obvious restriction. Plasma cells expressed predominantly IgG (c); of these, the majority (over 60%) were immunoreactive for IgG4 (d) (200x original magnification).
case_images: CRIRH2018-9602373.003.jpg
case_images: PMC6126084_01_CRIRH2018-9602373.003.jpg
case_images: fig3
case_images: CD138 (Figure 2(c)). Chromogenic in situ hybridization for kappa light chain (Figure 3(a)) and lambda light chain (Figure 3(b)) showed a mixture of kappa and lambda-bearing cells (approximate kappa to lambda ratio of 3 : 1); this finding suggested that the plasma cells were reactive in nature, arguing against the possibility of a plasma cell neoplasm. Additional immunohistochemistry showed that the plasma cells present expressed predominantly IgG (Figure 3(c)); of these, the majority (over 60%) were reactive for IgG4 (Figure 3(d)).
case_images: Top normal-sized pelvic lymph nodes decreased in size in repeat CT (4(b)) compared to previous CT (4(a)). The largest right external iliac lymph node measures 1.8 x 0.7 cm.
case_images: CRIRH2018-9602373.004.jpg
case_images: PMC6126084_01_CRIRH2018-9602373.004.jpg
case_images: fig4
case_images: A follow-up CT scan of abdomen after a month revealed significant reduction in the size of his pelvic lymph nodes with largest lymph node measuring 1.8 x 0.7 cm (Figure 4).
case_images: Endoscopic retrograde cholangiography showing presence of stricture in the biliary duct pre-ERC (a) compared to post-ERC (b).
case_images: CRIRH2018-9602373.005.jpg
case_images: PMC6126084_01_CRIRH2018-9602373.005.jpg
case_images: fig5
case_images: Endoscopic retrograde cholangiography (ERC) performed revealed resolution of stricture (Figure 5).