Case 650 -- A 67-year old man with high fever, fatigue and weight loss

Contributed by Somak Roy, MD and Fiona E. Craig, MD


This 67-year old man, with a past medical history significant for basal cell carcinoma, presented with prominent constitutional symptoms including high spiking fever, generalized pruritus, fatigue and 18 pound weight loss over 2 months. The patient underwent an upper gastrointestinal endoscopy and the possibility of gastric tumor was ruled out. Whole body computed tomography revealed generalized lymphadenopathy involving bilateral axillary, mediastinal, hilar, abdominal, retroperitoneal, bilateral iliac and inguinal regions. Bilateral pleural effusions were also noted. All intra-abdominal organs including liver and spleen were unremarkable. Initial laboratory tests revealed mild thrombocytopenia and raised alkaline phosphatase levels. Multiple blood cultures and urine culture were negative.


The histologic sections of the inguinal biopsy specimen demonstrate a lymph node with partially preserved architecture characterized by presence of few lymphoid follicles with rare germinal centers and a markedly expanded interfollicular area infiltrated by an abnormal lymphoid population (Fig 1, 40x H&E; Fig 2, 100x H&E). The infiltrate is comprised of predominantly intermediate size cells with irregular nuclear contours, clumped chromatin and small nucleoli with a moderate amount of cytoplasm. There are also occasional scattered large lymphoid cells with very large vesicular nuclei and prominent nucleoli. There is a prominence of thin arborizing high endothelial venules, along with a polymorphous cellular infiltrate comprised of eosinophils, few plasma cells and histiocytes (Fig 3, 500x H&E). The subcapsular sinus is identified, which appears patent and the lymphoid infiltrate appears to extend beyond the capsule into the surrounding perinodal soft tissue (Figure 1, 40x H&E).



Heterogeneous T-cells including some apparently CD10 positive T-cells, and a few polytypic B-cells.


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