A 57-year-old man was received in our department with a long acting fever, which had been developing for 3 months, weight loss, and profuse night sweats. He was a smoker (pack years were 10) and had neither regular medication nor a particular medical antecedent. Physical examination showed a poor performance status (PS = 4/5), clinical anemia, and diffuse lymphadenopathies at different sites: cervical, axillary, and inguinal. Pain and inflammatory swelling were also found particularly on knees, elbows, and interphalangeal joints. Pulmonary examination showed a diminution of vocal fremitus and the presence of coarse precipitations on the left side. Physical examination also revealed a 7 cm subcutaneous nodule, located in the anterior face of the right arm.
Blood count results showed hyperleukocytosis associated with anemia and thrombocytopenia (HB: 9.1 g/dl, MCV: 94 fl, WBC: 22600/mm3 with neutrophils: 53% and lymphocytes: 36%, and PLQ: 34400/mm3). Antinuclear autoantibodies were positive, and rheumatoid factors were high: 62 IU/ml. No bone marrow involvement was found after cytological examination.
A thoraco-abdominopelvic CT scan was performed and showed the presence of mediastinal and abdominal lymphadenopathies with necrotic centers and bilateral basal pneumopathy (Figure 1).
Diagnosis of multifocal tuberculosis was retained based on clinical symptoms and cytological examination of lymph node sample obtained by fine needle aspiration showing aspect of tuberculous adenitis and CT imaging.
Antituberculosis (TB) treatment (rifampicin, isoniazid, pyrazinamide, and ethambutol) was administered for two months, but it did not reduce clinical signs. A lymph node biopsy was then performed, and pathological analysis revealed a diffuse lymphomatous proliferation consisting of large atypical cells with clarified nuclei and immunostaining showed a lymphoid proliferation consistent with the diagnosis of AITL : EBV+, CD3+, CD5+, CD2+, CD4+, CD278+, CXCL13+, PD1a+/-, CD10+, and Ki67+. The time from the onset of signs to definitive diagnosis of AITL was 5 months. The patient was diagnosed at an advanced stage and was classified as IPI3 (Ann Arbor: IIIBb, PS: 4, and lactate dehydrogenase: 680 U/L).
Pretherapeutic evaluation revealed hyperuricemia and polyclonal gammaglobulinemia; all other results were normal (serology of HIV, hepatitis B and C, ionogram, urea, creatininemia, 24 hours proteinuria, alanine aminotransferase, aspartate aminotransferase, bilirubinemia, C-reactive protein, prothrombin time, activated partial thromboplastin time, fibrinemia, fasting blood glucose, and cardiac ultrasound).
Chemotherapy according to CHOP protocol (cyclophosphamide: 750 mg/m2, hydroxydaunorubicin: 50 mg/m2, vincristine: 1.4 mg/m2, and prednisone: 40 mg/m2), applied every 21 days, was performed. After 8 cycles of CHOP, complete remission was achieved with normalization of clinical and biological anomalies. A relapse occurred 5 months later, and treatment consisted of 2 additional CHOP cures followed by 2 COP cures. A complete clinical and radiological remission was achieved again. Currently, one year after stopping treatment, the patient remains with no clinical symptoms; biological and morphological explorations are normal. Considering complications during treatment, febrile neutropenia was noted after the first treatment, and the patient was treated with G-CSF and antibiotics (3rd generation cephalosporin + gentamicin) for a duration of 10 days. Other complications were alopecia and nail hyperchromy.