The Clinical Problem Solvers Episode 112: Virtual Morning Report #100 with Rabih, Reza, and Dr. Rezigh – Rash and lactic acidosis
Dr. Rezigh presents a clinical unknown on Virtual Morning Report to CPSolvers, Rabih and Reza.
Episode Summary
A 75-year-old-woman with multiple chronic medical problems presented with right arm pain, anorexia, and diffuse erythematous nodular plaques. Her work up was notable for an elevated serum lactate and S1Q3T3 pattern on ECG. Computed tomography of the chest, abdomen, and pelvis demonstrated a right pleural effusion as well as nodular soft tissue thickening surrounding the right atrium extending to the interatrial septum with local mass effect and narrowing of the superior vena cava. Biopsy of her rash revealed abnormal lymphoid proliferation. Further studies led to a diagnosis of diffuse large B-cell lymphoma (DLBCL) with prominent cutaneous manifestations.
Teaching Point
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin’s lymphoma and can have a diverse range of manifestations. Most often, patients present with a rapidly enlarging mass and/or systemic “B-symptoms” (e.g., fever, night sweats, weight loss). Laboratory abnormalities classically include elevated lactate dehydrogenase levels, which occur in >50% of patients. In a minority of patients (about 40%), DLBCL presents in extramedullary and extranodal locations, including the soft tissues, lung, endocrine organs, and central nervous system. Diagnosis requires histologic examination and immunophenotyping (flow cytometry, immunohistochemical staining).