Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

Diffuse large B-cell lymphoma in peritoneal fluid
Savaille, J, D.O.; Sheth, S, MD.; Garretson, L, M.D.; Awkar, N, M.D.; Guron, G, M.D.
St. Michael’s Medical Center, Newark, NJ
Introduction: Diffuse large B-cell lymphoma (DLBCL) represents the majority of Non-
Hodgkin’s lymphoma. Any organ in the body can be involved. The primary site can be a
primary lymph node or extra-nodal tissue. However, it is uncommon to identify DLBCL in
a body cavity with the absence of any tumor mass lesions. The pleural, pericardial or
peritoneal cavity may be affected. The following case discusses an atypical presentation
of new-onset ascites.
Case: A 74-year-old male with a past medical history of diabetes mellitus type II,
hypertension, liver cirrhosis, history of Hepatitis C and history of alcohol abuse was
admitted for abdominal distension for three week’s duration. Physical examination was
significant for only massive ascites. Complete blood count on admission revealed a
WBC 4.9 k/uL, Hb 12.1 g/dL, HCT 36.9%, Plt 127 k/uL and MCV 98.5. Other pertinent
laboratory studies included alkaline phosphatase 192 IU/L, AST 52 IU/L, ALT 42 IU/L,
LDH 197 mg/dL. HIV and Hepatitis B serology were negative, whereas Hepatitis C was
positive. Hepatitis C viral load was undetectable. HHV-8 serology was negative. During
the hospital course, a 6-liter abdominal paracentesis was performed on which cytology
was positive for malignant lymphoid cells. Flow cytometry analysis revealed cells
positive for kappa light chain, CD10 with CD19, CD20 and CD22. Immunoperoxidase
analysis showed positivity for CD79a, CD10, bcl-6, bcl-3, CD20 and negative for bcl-1.
Additionally, ki-67 showed high proliferative index. Fluorescence in situ Hybridization
showed no rearrangements of the MYC gene. Bone marrow biopsy revealed
normocellular marrow for age and no other abnormalities. Staging studies including a
CT scan of the chest, abdomen and pelvis was performed with no evidence of
lymphadenopathy. A PET-scan was done which was unremarkable. Two months after
discharge the patient was started on R-CHOP chemotherapy. After receiving
chemotherapy, repeat peritoneal fluid cytology was negative for malignant cells. Despite
chemotherapy, patient still had recurrent ascites.
Discussion: We present a case report of DLBCL identified in peritoneal fluid with no
evidence of solid tumor lesions. The diagnosis is solely made on the fluid analysis.
Therefore, body cavity fluid should always include cytology and cell count with
differential. Although the patients’ ascites did not improve after receiving chemotherapy,
DLBCL usually has a favorable response to chemotherapy.