Abstract
A 67-year-old man presented with a 3-day history of abdominal pain, fever, and significant weight loss over 2 months. Physical examination revealed left upper quadrant tenderness, hepatomegaly, splenomegaly, and bilateral pitting edema but peripheral lymphadenopathy was absent. Laboratory tests showed anemia, thrombocytopenia, elevated prothrombin time (PT), partial thromboplastin time (PTT), and increased lactate dehydrogenase (LDH). PTT was corrected completely in mixing study. Further workup for the cause of coagulopathy revealed decreased levels of all clotting factors except factor VIII and increase fibrinogen levels, which ruled out disseminated intravascular coagulation (DIC). Flow cytometry of peripheral blood was normal. Contrast-enhanced computed tomography (CECT) revealed splenomegaly with multiple splenic infarcts without any mediastinal or intraabdominal lymphadenopathy. Further investigations for infective endocarditis (blood cultures and transthoracic echocardiography) and autoimmune disorders (ANA, dsDNA, RA factors) were negative. The patient received treatment for sepsis empirically without any significant clinical improvement. The diagnosis remained unclear despite extensive workup and liver biopsy was conducted due to high suspicion of granulomatous diseases. However, the liver biopsy revealed high-grade diffuse large B-cell lymphoma (DLBCL). Unfortunately, patient died shortly after the diagnosis. Here we report a case of high-grade DLBCL with hepatosplenomegaly and splenic infarcts in the absence of any lymphadenopathy or focal lesions. This case highlights the fact that unusually lymphoma can present in the absence of lymphadenopathy or mass lesion mimicking autoimmune and granulomatous disorders. The diagnosis in these cases can only be made on histology, and hence the threshold for biopsy should be low in patients with unclear presentations and multiorgan involvement.
Highlights
Splenic infarcts are rare and result from the occlusion of splenic artery or one of its branches with an embolus secondary to septic emboli from the vegetations on the mitral or aortic valves or less frequently by localized thrombosis as seen in leukemia, myeloproliferative disorders, sickle cell disease, or in vasculitis.[1,2] It is described only rarely with diffuse large B-cell lymphoma (DLBCL).[3]
We report a rare case of splenic infarcts in a patient with DLBCL
This case illustrated a rare presentation of DLBCL, characterized by the absence of peripheral and internal lymphadenopathy, focal lesions, and the presence of diffuse hepatic involvement
Summary
Splenic infarcts are rare and result from the occlusion of splenic artery or one of its branches with an embolus secondary to septic emboli from the vegetations on the mitral or aortic valves or less frequently by localized thrombosis as seen in leukemia, myeloproliferative disorders, sickle cell disease, or in vasculitis.[1,2] It is described only rarely with diffuse large B-cell lymphoma (DLBCL).[3] We report a rare case of splenic infarcts in a patient with DLBCL Besides splenic infarcts, this case illustrated a rare presentation of DLBCL, characterized by the absence of peripheral and internal lymphadenopathy, focal lesions, and the presence of diffuse hepatic involvement. Due to high index of suspicion, echocardiogram was repeated after 1 week but it remained negative
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