for growth. Pleural fluid LDH was greater than two- thirds upper limit of normal serum LDH (220 U/L) and therefore significant for exudative pleural effusion. The patient presented for follow up at Rheumatology clinic now with synovitis of bilateral MCPs and MTPs. He was started on methotrexate and folic acid. Discussion: Normal pleural fluid has a pH of 7.60-7.66. The pH of transudates is generally higher (7.45-7.55) than exudates (7.30-7.40). Also, rheumatic effusion
is usually associated with pleural acidosis. However, LDH levels of greater than three times the upper limit of normal can be associated with rheumatoid pleurisy. The presence of eosinophilic effusion negative for malignancy and infection also directs towards an inflammatory condition. The patient was also found to have a positive p-ANCA but negative for anti-PR3, anti-MPO and anti-GBM which indicates further investigation for overlap syndrome of ANCA associated vasculitis with rheumatoid arthritis.
TRANSFORMATION OF FOLLICULAR B-CELL LYMPHOMA INTO DIFFUSE LARGE B-CELL LYMPHOMA IN A PATIENT WITH LATENT TUBERCULOSIS Allyson Larcena MD, Ibrahim Shenawi MD, Thomas Jason Simon MD, Mekha Matthew DO, Emma Domangue BS, Caroline Neck BS, Melanie Bienvenu MD; Department of Medicine, LSU Health, Lafayette, LA.
Introduction: Follicular lymphoma (FL) is a form of non-Hodgkin lymphoma that rarely occurs in the gastrointestinal tract. Most cases are indolent; however, transformation of FL to a more aggressive histology, such as diffuse large B cell lymphoma (DLBCL) is an important consideration due to poor outcomes unless treated promptly. Case: A 60-year-old female with a history of lung and thyroid nodules and chronic back pain presented with chronic early satiety, associated with unintentional twenty-six-pound weight loss and night sweats over one month. Computed Tomography of the abdomen and pelvis revealed a large stomach mass extending from the gastroesophageal junction along the lesser curvature to the antrum of the stomach consistent with malignancy. This prompted gastroenterology referral for endoscopy, which revealed a large, ulcerated mass on lesser curvature, spanning the gastroesophageal junction to the distal gastric body. Pathology was consistent with B cell lymphoma, with follicular center phenotype. During the next month, while awaiting oncology appointment for therapy initiation, the patient endorsed worsening abdominal pain and anorexia with minimal response to supportive therapy. She ultimately sought further management of recalcitrant pain, nausea, and vomiting and due to aggressive symptoms, oncology suspected transformation to large B cell lymphoma. Repeat endoscopy revealed
progression of tumor since prior endoscopy, with blood oozing from the gastric cardia, fundus, body, and lesser curvature of the stomach, and near complete obstruction of the cardia. Pathology revealed transformation of follicular B cell lymphoma to diffuse large B-cell lymphoma, germinal center type. Oncology believed that shrinking the tumor would lead to improvement of symptoms therefore, R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) was initiated with a rapid clinical response to treatment. Improvement most notably manifested in her ability to tolerate regular diet shortly after treatment was initiated. Of note, testing prior to initiation of chemotherapy included a positive Quantiferon Gold. Pleural fluid studies revealed negative adenosine deaminase and positive AFB; therefore, the patient was treated for latent tuberculosis with isoniazid and pyridoxine for nine months. Ten months after initial diagnosis, the patient underwent surveillance imaging, which revealed that gastric mass was decreasing in size. Repeat endoscopy with biopsy revealed no evidence of disease. Discussion: Though a rare occurrence, follicular lymphoma has the potential to transform to diffuse large b cell lymphoma, which is aggressive and rapidly growing, but responds well to chemotherapy. It is important to be cognizant of this potential and initiate treatment promptly for optimal outcomes.
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