pt 2 Non-Hodgkins Lymphoma or Lyme - differential diagnosis not easy 
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 pt 2 Non-Hodgkins Lymphoma or Lyme - differential diagnosis not easy

title:  Lyme disease meningopolyneuritis simulating malignant lymphoma
source:  Mod Pathol 1988 Nov;1(6):464-8

Abstract:  Lyme disease is a multisystem disorder resulting from infection by
the tick-borne spirochete, Borrelia burgdorferi.  Fever, chills and headaches;
a characteristic rash;  and subsequent polyarthritis typically herald the onset
of this condition.  Neurologic involvement may occur with skin and joint
manifestations or present alone as meningitis, cranial neuritis, and
radiculopathy known as Bannwarth's syndrome.  We report the cerebrospinal fluid
(CSF) cytomorphologic and immunocytochemical features of four patients who
presented with isolated meningitis, cranial neuritis, and painful neuropathy
without initial history of specific skin rash or previous tick bite.  Initial
CSF findings of significant numbers of markedly atypical plasmacytoid
mononuclear cells suggested CSF non-Hodgkins malignant lymphoma.
Immunocytochemical studies on CSF specimens, however, revealed polyclonal
surface immunoglobulin patterns consistent with an inflammatory reaction.
Follow-up clinical history and/or peripheral {*filter*} serologic testing for
antibody titers with B. burgtdorferi antigen confirmed the diagnosis of Lyme
disease in all four cases.  We conclude that Lyme disease may present as
atypical spinal fluid lymphoplasmacytic cellular infiltrates that simulate
malignant lymphoma and that appropriate immunocytochemical studies and
peripheral {*filter*} serologic testing be performed to establish this diagnosis and
direct appropriate therapy.

Address:  Department of Pathology, Harvard Medical School, Boston,
Massachusetts.
________________________

title :  Clinical Manifestations of Lyme Disease in the United States
authors:  Trock, et al  (Yale University School of Medicine, New Haven, CT.)
source:  Connecticut Medicine, June 1989  Volume 53,  NO. 6  pg. 327-30

.............."Borrelia Lymphocytoma"
    "A rare early cutaneous manifestation of Lyme disease is borrelia
lymphocytoma, a tumor-like violaceous swelling or nodule at the base of the
earlobe or the {*filter*} caused by a dense lymphocytic infiltrate of the dermis.
This lesion occurs at the site of a tick bite, is usually solitary, and may be
associated with regional lymphadenopathy.  In the setting of fever, fatigue,
and adenopathy, borrelia lymphocytoma can be confused with a lymphoma.
Untreated, this lesion may linger for 6-12 months before it disappears
spontaneously......"
____________________________--

St. von Orellia, B. Schnarwylera, R. Maurerb, H. Hirschc, B. von Castelberga a
Maternit Inselhof Triemli und b Institut fr Pathologie, Stadtspital Triemli,
Zrich, und c Institut fr medizinische Mikrobiologie,
Universit?t Basel, Schweiz
Vulv?res Pseudolymphom: Nachweis der Infektion mitBorrelia burgdorferi mittels
Polymerasekettenreaktion
Originalarbeit
Gyn?kologisch-geburtshilfliche Rundschau 1998, 38:3:143-145.

We report on a 42-year-old patient with a vulvar pseudolymphoma in association
with an infection with Borrelia burgdorferi. The diagnosis was made using PCR
amplification on a paraffin-embedded tissue sample. The lesions healed
completely within 3 weeks of {*filter*}doxycycline therapy.
________________________

Primary cutaneous immunocytoma. A B-cell lymphoma that can easily be mistaken
for cutaneous lymphoid hyperplasia.
Authors:LeBoit PE, McNutt NS, Reed JA, Jacobson M, Weiss LM
Source:Am J Surg Pathol 1994 Oct;18(10):969-78
Organization:Department of Pathology, University of California, San Francisco
94143-0506.

Abstract:
It has been estimated that immunocytomas comprise roughly 2% of all cutaneous
lymphomas. We studied five patients with primary cutaneous immunocytomas who
presented with cutaneous nodules or plaques. Many of the infiltrates were
top-heavy and polymorphous with admixed eosinophils, macrophages, lymphoid
follicles, and non-neoplastic lymphocytes. Other potentially confusing findings
were one case each of spongiotic dermatitis and leukocytoclastic vasculitis.
The neoplastic cells were often situated at the peripheries of nodules and
ranged from those with nuclei that resembled small lymphocytes to others that
resembled immunoblasts. Most had eccentrically placed nuclei and fan-shaped
cytoplasm. Monotypic kappa-light chain was found in all five cases, accompanied
by gamma-heavy chain in two cases, and mu-heavy chain in one. In situ
hybridization detected only kappa-mRNA in the four cases that yielded
technically satisfactory results. The neoplastic cells did not express the
B-cell antigen CD20; T-cells formed the centers of many nodules. Inappropriate
staining for CD43 was evident in the neoplastic cells of one case. Because of
reports of immunocytomas complicating acrodermatitis chronica atrophicans, we
stained sections with an antiserum to Borrelia burgdorferi, which did not
detect that organism. In situ hybridization did not detect EBER-1 RNA of the
Epstein-Barr virus, which can be present in immunocytomas in immunocompromised
patients. One patient died of disease after failing chemotherapy; another is
alive with disseminated disease, and three are in remission following excision
of lesions alone in two patients and chemotherapy in one patient who had
relapsed following both excision and radiation therapy.
.Language: Eng

Unique ID: 94379324
______________________
New cutaneous manifestations of systemic diseases.
Authors:Khorenian SD, Lebwohl M
Source:Am Fam Physician 1995 Feb 15;51(3):625-30
Organization:Mount Sinai Medical Center, New York, New York.

Abstract:
In recent years, especially with the advent of acquired immunodeficiency
syndrome, new skin disorders associated with systemic disease have been
described in the literature. Eosinophilic folliculitis and pruritic papules of
human immunodeficiency virus (HIV) infection are clinically similar lesions
that respond to phototherapy. Bacillary angiomatosis,[cat scratch fever -
bartonella] another HIV-related skin
disease that is caused by a pleomorphic gram-negative organism, resembles
Kaposi's sarcoma clinically but is curable if treated early with antibiotics.
Toxic strep syndrome, a scarlatiniform, desquamative eruption associated with
hypotension, fever and multiorgan system dysfunction, is caused by group A
streptococcal soft tissue infection. Paraneoplastic pemphigus, a recently
characterized autoimmune vesicular eruption, produces painful mucocutaneous
ulcerations in patients with an occult neoplasm, such as chronic lymphocytic
leukemia or malignant lymphoma.

Language: Eng

Unique ID: 95168151

[Borrelia infections of the skin--progress of knowledge since the discovery of
Lyme disease]
Authors:Garbe C
Source:Hautarzt 1991 Jun;42(6):356-65
Organization:Universit:ats-Hautklinik und Poliklinik, Klinikum Steglitz Freien
Universit:at Berlin.

Abstract:
The description of Lyme disease in 1976 and the detection of its causative
agent, the spirochete Borrelia burgdorferi (B. burgdorferi), in 1982 led to an
increase in our knowledge of the course of B. burgdorferi infection and its
clinical manifestations. The classic tick-borne dermatoses erythema chronicum
migrans (ECM), lymphadenosis benigna cutis (LABC) and acrodermatitis chronica
atrophicans (ACA) were proven by isolation of the spirochete from skin lesions
to be caused by B. burgdorferi infection. In early disease (less than 1 year)
ECM and LABC can develop locally at the site of infection (stage I), but both
these skin manifestations can also occur together with multiple lesions after
dissemination of the causative organism (stage II). ACA is typical for late
infection (greater than 1 year, stage III). High titres of B. burgdorferi
antibodies have been found in patients with localized sclerodermalike lesions
(circumscribed scleroderma, lichen sclerosus et atrophicus, anetoderma), and
frequent simultaneous occurrence of ACA suggests an association with late B.
burgdorferi infection. Similarly, we found four cases of cutaneous B-cell
lymphoma possibly arising from LABC in association with the same markers of
late B. burgdorferi infection. Additionally, some cases of Sch:onlein-Henoch
purpura and of Shulman syndrome may be associated with Lyme borreliosis. The
disease is endemic in central Europe, and almost exclusively ticks of the
Ixodes ricinus complex seem to transmit B. burgdorferi to humans, whereas the
reservoir of infection seem to be rodents, especially mice. The main diagnostic
tool is serological examination for B. burgdorferi antibodies, which will
become detectable 3-6 weeks after infection. Enzyme-linked immunosorbent assay
(ELISA) and the indirect immunofluorescence test (IFT) revealed similar
sensitivity. In early disease, sensitivity for antibody detection could be
improved by immunoblot technique and by flagellum-ELISA, which is specific for
this early sensitizing B. burgdorferi antigen. For treatments, penicillin is no
longer recommended as the drug of first choice, because low sensitivity of B.
burgdorferi has been observed in vitro and in vivo. Tetracycline, doxycycline
and amoxicillin p.o. are now preferred for the treatment of Lyme borreliosis,
and in neurologic and cardiac abnormalities ceftriaxone i.v. is recommended.
Treatment duration should be 14 days in early disease and 30 days in late
disease.

Language: Ger

Unique ID: 92010765
___________________________________

Early and late cutaneous manifestations in Ixodes-borne borreliosis (erythema
migrans borreliosis, Lyme borreliosis).
Authors:Asbrink E, Hovmark A
Source:Ann N Y Acad Sci 1988;539:4-15
Organization:Department of Dermatology, Karolinska Institute, S:odersjukhuset,
Stockholm, Sweden.

Abstract:
[No Abstract Available]

Language: Eng

Unique ID: 89048811
___________________________________________

[Benign cutaneous lymphocytoma of the {*filter*} areola and Erythema chronicum
migrans: a pathognomonic association of Lyme disease]
Authors:Gautier C, Vignolly B, Taieb A
Source:Arch Pediatr 1995 Apr;2(4):343-6
Organization:Unite de dermatologie pediatrique, hopital Pellegrin-Enfants,
Bordeaux, France.

Abstract:
BACKGROUND--Clinical manifestations of Lyme disease are mainly cutaneous,
neurologic, cardiac and/or located joints. Some dermatologic manifestations are
more specific. CASE REPORT--An eight year-old-girl was examined because she
suffered from a nodular lesion located on the left {*filter*} areola which appeared
3 months earlier. This lesion was associated with an expanding erythematous
annular lesion located on the anterior face of thorax and left axillary area,
without any lymphadenopathy. The association of this cutaneous lymphocytoma and
erythema chronicum migrans was suggestive of Borellia infection despite absence
of previous tick bite. Serologic tests (indirect immunofluorescence) were
negative, but both lesions disappeared within 2 weeks with ceftriaxone, 50
mg/kg/day. CONCLUSIONS--This association is pathognomonic of Lyme disease;
serologic tests may be found negative, but both lesions disappeared within 2
weeks with ceftriaxone, 50 mg/kg/day. CONCLUSIONS--This association is
pathognomonic of Lyme disease; serologic tests may be found negative in the
early stages of disease.

Language: Fre

Unique ID: 95299618
_______________________
Borrelial lymphocytoma--a historical case.
Authors: Sonck CE, Viljanen M, Hirsimaki P, Soderstrom KO, Ekfors TO
Source: APMIS 1998 Oct;106(10):947-52
Organization: Department of Dermatology, University of Turku, Finland.

Abstract:
We here describe a patient with a tick bite in the areola mammae in 1953
followed by erythema migrans. Twenty years later, after another tick bite in
the axillary skin, also followed by erythema migrans, a large lymphatic
infiltrate developed in the mammary skin, when the margin of the erythema
reached the areola. The infiltrate resolved within a year without any therapy.
Borrelial DNA was detected by polymerase chain reaction in the paraffin blocks
of the lymphatic skin infiltrate. The patient died 9 years later of generalized
lymphoma. A similar monoclonal immunoglobulin heavy chain gene rearrangement
was detected both in the mammary skin lesion and in the lymphoma specimen.

Language: Eng
________________________________________________________

"...the unusual clinical course preceding the diagnosis suggests that a
demyelinating disease may have preceded, and possibly heralded, the development
of primary CNS lymphoma......"

Case report of unusual leukoencephalopathy preceding primary CNS lymphoma

Keith Brecher,a Fred H Hochberg,b David N Louis,b Suzanne de la Monte,b Peter
Riskindb

a Memorial Sloan-Kettering Cancer Center, New York, New York, USA,
b Massachusetts General Hospital, Boston, Massachusetts, USA

Correspondence to: Dr Keith Brecher, Memorial Sloan-Kettering Cancer Center,
Department of Neurology, 1275 York Avenue, New York, New York 10021, USA.

Received 17 October 1997 and in revised form 27 January 1998; Accepted 30
January 1998

A previously healthy 35 year old woman presented with bilateral uveitus
associated with multiple, evolving, non-enhancing white matter lesions
consistent with a progressive leukoencephalopathy such as multiple sclerosis.
Thirty months after her initial presentation, she was diagnosed with primary
CNS lymphoma and died 14 months later. The unusual clinical course preceding
the diagnosis suggests that a demyelinating disease may have preceded, and
possibly heralded, the development of primary CNS lymphoma. Cases of "sentinel
lesions" heralding the diagnosis of primary CNS lymphoma have been reported,
and this case further corroborates such instances and raises further issues
regarding possible neoplastic transformation occurring in inflammatory diseases
such as multiple sclerosis.
(J Neurol Neurosurg Psychiatry 1998;65:917-920)

Title: [Nervous system borreliosis with pseudo-lymphoma cells in cerebrospinal
fluid]
Authors: Kaminsky P, Grignon Y, Deibener J, Maurer P, Duc M
Source: Rev Neurol (Paris) 1998 Feb;154(2):170-2
Organization: Service de Medecine Interne, Centre Hospitalier Universitaire de
Nancy, Hopitaux de Brabois, Vandoeuvre.

Abstract:
We report the case of a 44-year-old woman, who experienced acute back pains,
leg paraesthesia, and diplopia. Analysis of the cerebrospinal fluid revealed,
in addition to increased protein and decreased glucose levels, an elevated
number of large atypical cells, resembling lymphoma cells. Magnetic resonance
imaging of the brain and spine was normal. High levels of antibodies against
Borrelia burgdorferi were found in both serum and cerebrospinal fluid. The
patient completely recovered with ceftriaxone therapy.

Keywords:
{*filter*}, Back Pain, Borrelia burgdorferi, ISOLATION & PURIF, Brain, PATHOLOGY,
Case Report, Diagnosis, Differential, Diplopia, English Abstract, Female,
Human, Lyme Disease, CEREBROSPINAL FLUID, DIAGNOSIS, PATHOLOGY, Lymphoma,
DIAGNOSIS, Magnetic Resonance Imaging, Paresthesia, Spinal Cord, PATHOLOGY

Language: Fre

Unique ID: 98446217
__________________________

"..... never once did I imagine that, after only
four years of love, on the threshold of marriage, I would learn that my
boyfriend,....,had a rare and hard-to-treat lymphoma.  
    "Last summer that happened..."

        "...... The doctors had no idea
what Mark did have but they were certain of what he did not:  no lymphoma, no
cancer.  Mark had been misdiagnosed...."

"Before all this, I believed science was exact and that the word of the doctor
was definitive.  ..."

source:  Bazaar magazine-Feb. 1997
  author:  Martha McPhee  

    "I've imagined many things:  that my plane will crash into the sea, that
I'll go to jail for a {*filter*} I didn't commit, that I'll get stuck in traffic
and be late and that the world will come to a shattering end.  My husband calls
me a "worst case scenarioist."   He says I have an apocalyptic
imagination....But in all of this, never once did I imagine that, after only
four years of love, on the threshold of marriage, I would learn that my
boyfriend,....,had a rare and hard-to-treat lymphoma.  
    "Last summer that happened.
    "It was July and  hot and we were at Yaddo, an artists' colony in upstate
New York......Mark,
who had been strong, fit and healthy, fell ill with a fever, chills and sweats
that eventually led us to a doctor and an Xray that revealed a mass in his
chest--an apparent ' widening of the mediastinum,'  a symptom of lymphoma.  A
CAT scan followed, then a biopsy, and then  the diagnosis:  rare peripheral
 T-Cell lymphoma. "
    The author goes on to tell of the options offered , options  like "a chemo
{*filter*}tail, radiation , the harvesting of bone marrow, bone marrow
transplants...With treatment, 40% survive; of this number some 30 to 50 % have
a relapse and then the figures become just plain bad.  I thought of Mark's
running eight miles a day and thought how mysterious cancer is."
    "Boom, just like that.  All my worrying, my attempts to control fate, were
not preparation for this.  And so began a medical odyessy that took over our
lives and the lives of our families.  We stopped working.  Our future closed up
like a fan."
     The author describes the horrible ordeal of the diagnostic phase.
"Early on Mark tested positive for mononucleosis---a relief until we learned
that mono is related to the Epstein-Baar virus, which can attach to the nucleus
of T-cell lymphoma to create a more virulent strain.  As soon as this was ruled
out we were terrorized by AIDS.  Lymphoma presents itself commmonly in AIDS
patients.  Mark was questioned about his drug and sex habits. ....Lymphoma,
lymphoma.  Our lives revolved around it.  We needed to learn a new language.
Differential diagnosis. Large cell and small, and B-cell and T-cell....We found
the BEST specialists in the country and we went to them for second and third
opinions.  Everything became about 'the best. '  This took us out of the
network of our HMO and cost us money we didn't have.... but if that was the
price of saving Mark, then there was no alternative.
     "We found ourselves sitting in plush leather seats in the office of 'the
best' lymphoma specialst in the world;  he called himself a 'lymphomaniac.'  He
examined the slides of Mark's biopsied tissue under a microscope.  He looked
very puzzled and pulled books off his shelf. What's wrong I wanted to scream.
He looked at us and said that he believed Mark had angiocentric lymphoma--a
strain even rarer than peripheral T-cell.
    "Down the street at 'the best' cancer institute in the country, we waited
for a third opinion, ....Finally we saw the doctor, who bluntly countermanded
the first and the second opinion, saying that Mark needed another biopsy.  His
hunch was that Mark had Hodgkin's disease--a highly treatable form of lymphoma,
with a 90% cure rate.
    "Who should we believe?  Each doctor had a convincing theory for his or her
opinion.....The questions began to avalanche, leaving us confused and
terrified.
    "To get the final diagnosis, this is what Mark had to go through:  the
first biopsy, which involved a a small incision beneath his neck; a bone-marrow
biopsy, a painful procedure with a long needle through the hip;  countless
{*filter*} tests and X rays; three oncologists; three pathologists; three hospitals;
two surgeons and at least 30 other doctors, from lung specialists to
anesthesiologists; five CAT scans; more than $40,000 in medical bills; a lot of
waiting, because by now it was late August and every single doctor we were
involved with had gone on vacation; and finally, the third biopsy, a procedure
that was similar to lung and open-heart surgery and that left Mark in the
hospital for three days, with tubes coming out of his urethra, nose, mouth, and
lungs, that left him with separated ribs, a collapsed lung, a thick red
eight-inch boomerang-shaped scar on his back, a cough that would later turn to
asthma, and a lethargy that wouldn't lift until late fall.
    "Finally the day came when we would learn the results.  There are few times
in life when so much rests on one answer.......Mark and I were prepared for the
struggle ahead......For once, I was actually in the worst-case scenario (or
pretty close), and oddly enough, there was something perversely comforting in
feeling that I finally knew the what the future held in store for us--even if
it would be filled with pain and suffering.
   "So the day came and we got the answer, and the answer was stunning, not
just to Mark and me but to all the doctors involved.  The doctors had no idea
what Mark did have but they were certain of what he did not:  no lymphoma, no
cancer.  Mark had been misdiagnosed.......
    "Three months have passed, and we've since learned that the lymph nodes in
Mark's chest have shrunk and that the most likely explanation for his illness
was a bacterial infection........What went so terribly wrong?...The doctors
concerned  were perplexed by the final diagnosis, but each had insisted the
case had been a complicated one. .......
"Before all this, I believed science was exact and that the word of the doctor
was definitive.  It stuns me now to think that, had we not had the wherewithal
and the family support to seek second opinions and get outside the HMO network,
Mark would be undergoing toxic chemotherapy treatment for a cancer he did not
have....."

_______________________________
 ``Lymphoma cells look like normal cells. It's not clear how they become
tumors,''

Antibiotics Successfully Treat a Rare Cancer (7/20)

DAN VERGANO
c.1999 Medical Tribune News Service

Some cases of stomach cancer went into complete remission following treatment
with antibiotics, Texas researchers are reporting.

      Many cancer experts now suspect that infections play a role in triggering
several types of cancer, said Dr. Gideon Steinbach of the University of Texas
M.D. Anderson Cancer Center in Houston, who led the study.

      For example, human papilloma virus seems to spur development of cervical
cancer. Cancers of the lymph cells, immune system stalwarts that travel
throughout the body to rid it of invaders, have been spotted at infection sites
in the salivary glands and lungs, said Steinbach, suggesting a connection.

      Looking at gastric lymphoma, an uncommon type of immune cell cancer found
in the stomach, Steinbach's research team tested the effects of antibiotic
treatment on 34 patients with early or middle stages of the disease. Lab tests
revealed that 28 of study participants also suffered from infection with H.
pylori, a bacterium that causes ulcers. The men received a regimen of several
antibiotics, such as tetracycline and amoxicillan, until their infections
cleared and were then observed for average of three years afterward.

      ``We found this malignancy is dependent on H. pylori for growth and in
some patients it regresses with antibiotic treatment,'' said Steinbach. Half of
the patients who tested positive for H. pylori achieved complete remission of
the stomach tumors. None of the six patients without the infection responded to
the treatment.

      Only one patient with cancer that had moved beyond his stomach responded
to the antibiotic treatment, said Steinbach. Patients may need to receive
antibiotics, typically two courses of different antibiotics for years in order
to clear up the most serious cases. People with gastric lymphoma but no signs
of H. pylori should receive chemotherapy immediately, suggested Steinbach.

      ``Lymphoma cells look like normal cells. It's not clear how they become
tumors,'' he added. In most cases of cancer triggered by infections, the tumor
cells have mutated and no longer need the infectious agent to continue their
growth. Gastric lymphoma appears to be unique in needing the infection to
persist in some cases. Steinbach theorizes that some growth factor brought to
the infection site by T cells, immune system cousins of the lymph cells,
stimulates the growth of the tumor cells. Inflammation at the site of
infections may be the trigger for other cancers of the immune cells, an area
under strong investigation by cancer researchers. ``There may be some surprises
ahead,'' said Steinbach.

      Since tumors that had escaped beyond the stomach were less likely to
succumb to antibiotics, the researchers believe those cancer cells have mutated
past their dependence on H. pylori. For those patients, radiation therapy may
offer the only hope for remission of the cancer, said Steinbach.

      The Texas researchers have added more patients to their antibiotic
treatment group but have not analyzed their outcomes yet. The study appeared in
the Monday edition of Annals of Internal Medicine, a publication of the
American College of Physicians - American Society of Internal Medicine in
Philadelphia.
      -----



Fri, 09 Jan 2004 09:49:28 GMT
 
 [ 1 post ] 

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