https://orcid.org/0000-0001-9274-0214
![A 61-year-old man without significant medical history presented with a several-week history of drenching night sweats, 30-pound weight loss, diarrhea, and increasing fatigue. His evaluation in the emergency room revealed hepatosplenomegaly with elevated lactate dehydrogenase (4086 U/L) and lactate (6.9 mmol/L). Examination of the peripheral blood demonstrated an elevated white blood cell count (25.5 × 109/L) with numerous large atypical cells with fine chromatin, prominent nucleoli, and copious cytoplasm, often with long cytoplasmic processes (panel A; Wright-Giemsa stain, 100× oil objective). There were admixed immature myeloid elements and nucleated red blood cells consistent with a leukoerythroblastic reaction (panel B; Wright-Giemsa stain, 100× oil objective), anemia (hemoglobin, 9.1 g/dL), and thrombocytopenia (platelets, 52 × 109/L). Flow cytometric analysis revealed that the large atypical cells were CD20 (bright), kappa-restricted B cells (panel C) and were negative for CD5, CD10, CD11c, CD25, and CD103. A similar population was identified on a subsequent bone marrow aspirate and trephine core biopsy, which showed a mixed interstitial and intravascular distribution of the large lymphoid cells (CD20; panels D-E; hematoxylin and eosin stain, 40× objective [D], CD20 with hematoxylin counterstain, 40× objective [E]). Cytogenetics demonstrated a complex karyotype with a BCL6 translocation but no evidence of MYC or BCL2 rearrangement. / This unusual presentation with leukemic involvement and an intrasinusoidal/intravascular pattern in the marrow with noncohesive growth can be seen with splenic diffuse large B-cell lymphoma. It frequently involves the liver and follows an aggressive course.](https://ash.silverchair-cdn.com/ash/content_public/journal/blood/130/20/10.1182_blood-2017-08-800094/4/m_blood800094f1.jpeg?Expires=1735830376&Signature=4bxg9LT4Gre6413dTItLbM7DF6Q7VJ-b87ogKZzXvYpDfxdn2ZlfUqYz-pHMv0GZASZgYG-4bB9rR0FPoSaTLQbQg9VjL480ocMXHvUrE9oy9fb4SCAimRuMZ4tG~mwTWx2rteZgkLPX7VzPOrIRrr2oMhyH65doZoQYP4EnocQaEufp2kVITdyT3RW-Chs2z7-LthMTqXg5HycTyPuK1WTBbZSKFyo43NOsiPE8WpIgy2n~V4ZeVc1oulPDL9hTToqn~A~Q~GoP23tg6J1MZMdUUmGN42CPmi5a0TtiQaNoBjvS4oFd41bDs-yNFYBOJjYqSLKuEMcQ7eJpearRxQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA)
A 61-year-old man without significant medical history presented with a several-week history of drenching night sweats, 30-pound weight loss, diarrhea, and increasing fatigue. His evaluation in the emergency room revealed hepatosplenomegaly with elevated lactate dehydrogenase (4086 U/L) and lactate (6.9 mmol/L). Examination of the peripheral blood demonstrated an elevated white blood cell count (25.5 × 109/L) with numerous large atypical cells with fine chromatin, prominent nucleoli, and copious cytoplasm, often with long cytoplasmic processes (panel A; Wright-Giemsa stain, 100× oil objective). There were admixed immature myeloid elements and nucleated red blood cells consistent with a leukoerythroblastic reaction (panel B; Wright-Giemsa stain, 100× oil objective), anemia (hemoglobin, 9.1 g/dL), and thrombocytopenia (platelets, 52 × 109/L). Flow cytometric analysis revealed that the large atypical cells were CD20 (bright), kappa-restricted B cells (panel C) and were negative for CD5, CD10, CD11c, CD25, and CD103. A similar population was identified on a subsequent bone marrow aspirate and trephine core biopsy, which showed a mixed interstitial and intravascular distribution of the large lymphoid cells (CD20; panels D-E; hematoxylin and eosin stain, 40× objective [D], CD20 with hematoxylin counterstain, 40× objective [E]). Cytogenetics demonstrated a complex karyotype with a BCL6 translocation but no evidence of MYC or BCL2 rearrangement.
This unusual presentation with leukemic involvement and an intrasinusoidal/intravascular pattern in the marrow with noncohesive growth can be seen with splenic diffuse large B-cell lymphoma. It frequently involves the liver and follows an aggressive course.
A 61-year-old man without significant medical history presented with a several-week history of drenching night sweats, 30-pound weight loss, diarrhea, and increasing fatigue. His evaluation in the emergency room revealed hepatosplenomegaly with elevated lactate dehydrogenase (4086 U/L) and lactate (6.9 mmol/L). Examination of the peripheral blood demonstrated an elevated white blood cell count (25.5 × 109/L) with numerous large atypical cells with fine chromatin, prominent nucleoli, and copious cytoplasm, often with long cytoplasmic processes (panel A; Wright-Giemsa stain, 100× oil objective). There were admixed immature myeloid elements and nucleated red blood cells consistent with a leukoerythroblastic reaction (panel B; Wright-Giemsa stain, 100× oil objective), anemia (hemoglobin, 9.1 g/dL), and thrombocytopenia (platelets, 52 × 109/L). Flow cytometric analysis revealed that the large atypical cells were CD20 (bright), kappa-restricted B cells (panel C) and were negative for CD5, CD10, CD11c, CD25, and CD103. A similar population was identified on a subsequent bone marrow aspirate and trephine core biopsy, which showed a mixed interstitial and intravascular distribution of the large lymphoid cells (CD20; panels D-E; hematoxylin and eosin stain, 40× objective [D], CD20 with hematoxylin counterstain, 40× objective [E]). Cytogenetics demonstrated a complex karyotype with a BCL6 translocation but no evidence of MYC or BCL2 rearrangement.
This unusual presentation with leukemic involvement and an intrasinusoidal/intravascular pattern in the marrow with noncohesive growth can be seen with splenic diffuse large B-cell lymphoma. It frequently involves the liver and follows an aggressive course.
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