Written informed consent was obtained from the patient for publication of this case report and accompanying images. In October 2011, a 69-year-old white man presented with 15% weight loss (22 kg), mental confusion, nocturnal fever, difficulty in ambulation, limb weakness and general fatigue experienced over the previous 9 months. Physical examination revealed hepatomegaly, palpable 3 cm below the right costal margin, without lymphadenopathy or splenomegaly.
The results of the complete blood count were normal apart from mild leukocytosis (white blood cell count: 13,340/muL). The results of liver function tests were aspartate aminotransferase (AST): 58 U/L, alanine aminotransferase (ALT): 130 U/L, gamma-glutamyl transferase (GGT): 305 U/L, alkaline phosphatase (ALP): 601 U/L, total bilirubin (TB): 0.7 mg/dL and albumin: 3.4 g/dL. Lactate dehydrogenase (LDH) level was found to be 2648 U/L. Results of serologic tests for hepatitis B virus, hepatitis C virus, human immunodeficiency virus, and human T-lymphotropic virus-1 were negative. FAN and VDRL were negative. Tumor markers levels are described as follows: carcinoembryonic antigen (CEA): 0.3 ng/mL, carbohydrate antigen 19-9 (CA 19.9): 7.0 U/mL, and alpha-fetoprotein (AFP): 4.58 ng/mL.
Magnetic resonance imaging (MRI) findings showed a hypointense area on T1-weighted images sized of 13 cm x 9 cm x 11 cm, and hyperintense on T2-weighted images (Fig. 1a). There was no mediastinal lymphadenopathy or brain involvement on CT scan.
Two ultrasonography-guided needle liver biopsies were found negative and the third one showed diffuse infiltration of large sized lymphoid cells. Immunohistochemistry (Fig. 2): positive CD45-LCA, positive CD20; positive Ki67 in 80% of atypical cells; CD99 positive; vimentin positive. CD3, CD15, CD30, ACT, CK, CRO, DES, HMB45, and S100 were all negative. The diagnosis of primary large cells non-Hodgkin B-cell lymphoma was made.
Bone marrow aspiration and biopsy examination showed no evidence of diffuse large B-cell lymphoma.
The patient received R-CHOP treatment (cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab) in 8 cycles throughout 12 months. Two sessions of radiotherapy were also implemented.
In this case report, the patient showed a good response to treatment with mild side effects. After 6 months, the lesion decreased in size to 7 cm x 5 cm (Fig. 1b). After 24 months of follow-up, the patient remained asymptomatic. However, imaging studies have shown the persistence of a small calcified lesion of 3 cm x 1.5 cm (Fig. 1c). The patient has been regularly seen in an outpatient facility.