The patient was a 46 year old man first seen in February 2009 with a referral from a Private Facility in Lagos state. He presented with a 5 month history of generalized lymphadenopathy, weight loss and low grade pyrexia. Essential findings on physical examination included bilateral axillaries', inguinal, submandibular lymphadenopathy, size ranging from 2x2cm to 2x6cm; bilateral paedal oedema up to the groin, including scrotal and penile oedema, and non- tender generalized sub-cutaneous nodules. Examination of other systems was normal.
Preliminary report of FNAC received by the Institution histopathologist was reactive follicular hyperplasia. But subsequently two biopsy, one of subcutaneous nodule and the other of an inguinal lymph node were performed and the histology pattern of both biopsy was consistent with Non-Hodgkin's Lymphoma of T-cell rich diffuse large B-cell lymphoma (Figure 1) as certified by two independent pathologists. This diagnosis was quently subseconfirmed by immunohistochemistry showing reactive cells were positive for CD3, CD5 and Bcl2 while the neoplastic cells component were CD20 positive; CD10 and cyclin D1 was negative. All the same, a third opinion was sought from the institution's histopathologist, the histology report came much later (because of logistic reasons) as Hodgkin's Disease, Mixed Cellularity sub-type. As at that time of receiving this third opinion report, treatment had being commenced because of the poor state of the patient and patient had shown very good response to 4 cycles of CHOP(Cyclophosphamide Adriamycin, Oncovin and prednisolone) chemotherapy.
Further investigations included Abdominal Ultrasound which reported para-aortic and para-iliac lymphadenopathy, chest X-ray showed bilateral streaky opacities in both lung fields suggestive of Pulmonary tuberculosis and bone marrow aspiration showed significant (about 30%) abnormal lymphoid infiltration. He had normal biochemical findings; retroviral screening and VDRL were negative
After well tolerated 4 cycles of CHOP, there was a total regression of the enlarged lymph nodes and other accompanying signs. Also, FBC and biochemical investigations were within normal. At this juncture, chemotherapy was suspended for about 3 months and the waiting period was used to source for Rituximab. At the tail end of the third month, he had evidence of left lobar pneumonia and features of disease progression vis a vis recurrence of lymph nodes, reappearance of skin nodules at the trunk and elevated liver enzymes. The pneumonia responded to combination of antibiotics. When he subsequently commenced 21 day cycle of R-CHOP, of which he had six cycles, there was impressive evidence of disease remission.
However, patient developed right cervical lymphadenitis and abscess collection after the 5th cycle of R-CHOP. This was drained and the aspirate which was sent for culture yielded Klebsiella, sensitive to Levofloxacin and which the patient had for 3 weeks. Three weeks after the resolution of the right cervical abscess he developed peri-anal abscess which had to be drained by the surgeons. Retroviral screening was negative but HBsAg was positive. He also developed numbness of both feet with progressive inability to walk. This was initially thought to be induced by vincristine.
While awaiting Neurologists review in respect of his inability to walk on outpatient basis, he was brought acutely ill with greenish tinge jaundice, inability to walk, recurrence of ishiorectal abscess, distended abdomen with soft tender hepatomegaly of 12cm and soft tender splenomegaly of 8 cm. While LFT was suggestive of obstructive jaundice; abdominal USS confirmed splenic abscess and presence of hepatomegaly. The result of CT - Abdomen showed evidence of para-spinal infiltration.
He was commenced on I.V. antibiotics (Ceftrazone and Flagyl) while exploring the possibility of draining the abscess. He later developed haematochezia possibly due to acquired coagulation failure. He was supported with blood and blood products. Patient succumbed to the disease at this point.