Abstract
Diffuse Large B-Cell Lymphoma (DLBCL) is the most common type of Non-Hodgkin Lymphoma worldwide. It is an aggressive lymphoma that arises from germinal center or post-germinal center B cells. Patients typically present with a rapidly enlarging symptomatic mass, most usually nodal enlargement in the neck or abdomen, but may present with a mass lesion anywhere in the body. However, multiple sites of involvement occur less frequently. We report a case of a 74- year-old woman who initially presented to the hospital for evaluation of a right distal femoral fracture which resulted from a fall at home. Lytic lesions were found in the distal femur and proximal fibula. She was also found to have hypercalcemia with a calcium level of 12.2. A CT- guided biopsy confirmed the diagnosis of Diffuse Large B-Cell Lymphoma with non-germinal center phenotype. A radical resection of the right femur was performed, and a distal femoral replacement hinged knee arthroplasty was done successfully. A venous port was also placed for chemotherapy administration. The patient was admitted to inpatient rehab with plans to initiate chemotherapy. 6 weeks later, the patient presented to the emergency department (ED) with a chief complaint of difficulty hearing, ear discomfort, dysphagia, and dyspnea for 3 weeks. These symptoms prompted her medical oncologist to send her to the ED and postpone chemotherapy that was to begin on that day. Physical examination found the patient to have neck fullness, large palpable lymph nodes, and stridor. Upon evaluation she was also found to have impaired renal function (Blood urea nitrogen 41, Cr 3.10), severe hypercalcemia (Corrected calcium 16.2), and hypokalemia (Potassium 2.8). An EKG demonstrated sinus rhythm and non-specific t-wave abnormality. A chest radiograph showed an enlarged thyroid extending into the superior mediastinum. There was also tracheal narrowing, and tracheal deviation to the left. She was admitted to the Intensive Care Unit (ICU) for treatment of hypercalcemia and stridor. The patient was aggressively treated with fluid management. She also received loop diuretics, steroids, and calcitonin. Once stabilized, a fine needle aspiration of the thyroid gland identified further involvement by diffuse B-Cell Lymphoma. The medical oncologist then initiated R-CHOP chemotherapy. The stridor resolved and the patient’s symptoms significantly improved. After two weeks in the ICU she was discharged to a rehab facility where chemotherapy was continued. This is a rare case of rapidly growing non-germinal center DLBCL that presented with involvement of both the bone and thyroid gland causing life-threatening symptoms. Upon reviewing the literature, there has been no documented cases of DLBCL simultaneously involving the bone and thyroid gland. The patient responded well to R- CHOP chemotherapy and continues to receive treatment in an outpatient facility.
Primary Thyroid Diffuse Large B-cell Lymphoma in a Child with Hashimoto’s Thyroiditis: A Case Report
