17 years male with recurrent fever and weight loss .CT abdomen showed splenomegaly and para aortic lymph nodes. PPD negative. laparotomy splenectomy and lymph node biopsy showed necrotizing granuloma in spleen consistent with TB while lymph node showed possible small lymphocytic lymphoma . Is this possible , how to manage .?
Dear colleague,
It is absolutely possible to find many different diseases at the same time in the same person. Especially patients with small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL syndrome) have T cell immune depletion and they can have TBC, or other cancers like carcinomas especially in long course of the disease. I have many patients with urinary, lung or gastrointestinal cancers which developed in patients with SLL/CLL which was diagnosed after the primary solid malignancies.
Your patient is very young to have SLL/CLL, but it is however possible. Go to NCCN/or ESMO recommendations to see how to manage SLL/CLL. Only symptomatic disease requires treatment (constitutional symptoms-B symptoms, fever, weight loss, cytpoenias, autoimmune phenomena etc.). Your case is very debatable since you have very young patient with SLL/CLL who already have TBC. Look at his HIV status, and immune status , level of CD4 T cells, CD4/CD8 ratio, and level of B cells-this can be seen through flowcytometry. TBC should be treated immediately and than see if this diagnosis of CLL is correct and than if so, younger patients are treated with R-FC x 6 cycles as a standard of care according to results of CLL8 study by Fisher et all.
Sincerely,
Ivan
YES. This combination is not uncommon in patients with immunodeficiency syndromes including AIDS. You must carry out HIV screen, T cell subsets and immunoglobulin levels. As to the treatment, it will depend on number of factors (histological subtype, stage, complications etc). If it is low grade NHL and the disease is not advanced, he may not need immediate treatment and you may focus on treating his TB. You may want to give us the final histology and the results of the staging investigations including marrow biopsy if you need more precise advice.
Siva
Yes it is possible.
One of my case report which was published on Oncopedia in St.Judes online journal.
Tuberculosis Lymphadenitis in a Child with Hodgkin Lymphoma Oncopedia #395 Clinical Findings.
www.cure4kids.org
thanks all
the patient has no HIV , he was started on anti TB for the spleen. the pathologist asked for molecular testing of monoclonality
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