A BLOODY LYMPHOMA! Sneha Puvvada MD, Bhagya Challa MD, Maithri Vallabhaneni MD, Raja Saravanan MD, Sanjay Juneja MD; Department of Medicine, Baton Rouge General Medical Center; Baton Rouge, LA.
Introduction: Primary renal lymphoma (PRL) is a rare form of Non-Hodgkins Lymphoma with an incidence rate of less than 1% of all renal masses. As lymphoid tissue is absent in the kidneys, the genesis of PRL is uncertain. Our patient in this case study was incidentally diagnosed with PRL during a routine work up for iron deficiency anemia. Case: A 58-year-old post-menopausal woman with chronic cystitis with hematuria and recurrent UTIs presented for recurrent syncopal episodes and symptomatic iron deficiency anemia, that has been refractory to oral iron. She denied weight loss or anorexia but did have related night sweats. The patient did not have any signs of malabsorption, and evaluation with endoscopy was unrevealing. Flow cytometry and PNH were obtained for findings of worsening renal impairment with persistent lymphocytosis which produced negative results. Low levels of free light chains ruled out plasma cell dyscrasias. Renal ultrasound and follow up computed tomography confirmed a 3mm faint focus on the left lower pole. Her IgA levels and elevated inflammatory markers raised concerns for
immune complex glomerulonephritis for which a percutaneous kidney biopsy was obtained which unexpectedly revealed atypical lymphocytic infiltration. The diagnosis of PRL was validated by repeatedly negative results from subsequent PET scans and bone marrow biopsies. The patient was initiated on Bentamustine-Rituximab (BR) therapy and has shown to have favorable outcomes thus far. Discussion: Research indicates that PRL is more prevalent in men, organ transplant recipients, HIV patients, and individuals with unchecked Ebstein Barr Virus proliferation. PRL can easily be mistaken for renal cell carcinoma (RCC), particularly when it is a solitary lesion like this case. Nephrectomy is the usual course of treatment for RCC, while neoadjuvant chemotherapy would take precedence over nephrectomy in the case of PRL. This calls into doubt the long-held belief that in cases of renal masses, preoperative biopsies are not necessary before nephrectomy. Because of the aggressive nature of this disease, a delayed diagnosis results in poor prognosis; hence, an accurate diagnosis is crucial.
ORAL PRESENTATIONS – RESIDENTS SESSION 2
DECODING SINUSITIS: EXPLORING THE COMPLEXITIES Manush Sondhi, MD1; Chinedum Okafor, MD2; Samina Hayat, MD3, Department Medicine1, Department of Pathology2, Section of Rheumatology3, LSU Shreveport, Shreveport, LA.
Introduction: Aspirin-exacerbated respiratory disease (AERD) is defined as asthma, chronic rhinosinusitis with nasal polyposis, and hypersensitivity to cyclooxygenase 1 inhibitors. Immunoglobulin G4-related disease (IgG4-RD) is associated with reactive eosinophilia in one-third of patients. IgG4-RD and AERD can coexist in the sinonasal cavity, posing a diagnostic challenge. Case: A 52-year-old man with history of asthma and allergy to aspirin (confirmed by formal aspirin challenge) presented with chronic nasal congestion, thick yellow-green nasal discharge, post-nasal drip, and headaches for several months which worsened over the course of a week. He also experienced
intermittent shortness of breath, wheezing, coughing, and chest tightness. Lab results revealed elevated eosinophil levels (18.2%) and absolute eosinophil count (12.4). Computed tomography (CT) of the sinus revealed severe pansinusitis with opacification of all sinuses, while the CT of the chest showed diffuse patchy small airway disease. Otolaryngology identified bilateral nasal polyposis confined to the middle meatus (grade 4), but the patient declined invasive surgery. He was referred to Allergy and Immunology, where tests revealed elevated tryptase (33.4) and IgE levels (1470). He was treated with antihistamines and decongestants. Further evaluation by Hematology/Oncology showed normal flow cytometry, bone marrow findings, and negative
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