Luis A. Guarda

Primary lymphoma of the liver ten cases and a review of the literature

Ten adult white patients (21–75 years old; six women, four men) presented with large cell lymphoma of the liver. Each complained of abdominal pain and/or an abdominal mass, and five had B‐symptomatology of weight loss, fever (one patient), and night sweats (three patients). At laparotomy (eight patients) or by computerized tomography, liver‐spleen scan and lymphangiogram (two patients with percutaneous liver biopsy only), the liver was the sole site of involvement, although subsequent staging procedures revealed bone marrow involvement in three patients. Initial biopsy interpretation was incorrect in four cases which were diagnosed as poorly differentiated carcinoma. Although uncommon, the differential diagnosis of primary liver lymphoma should be entertained when patients present with solitary (three cases) or multiple (six cases) liver defects, particularly when alpha‐fetoprotein and carcinoembryonic antigen levels are normal. One patient had diffuse hepatomegaly. Treatment included biopsy (eight patients) or resection (two patients) followed by combination chemotherapy. All patients are alive from 0 to over 10 years (mean, 2.4; median, 1.8 years): six in complete remission, two with less than 6‐months follow‐up, and two with recurrent lymphoma. Examination of this group of patients along with 19 cases identified in the literature suggests that this is a more treatable disease than primary liver carcinoma.

Bone marrow biopsies in patients with the acquired immunodeficiency syndrome

Bone marrow biopsy findings in 32 homosexual patients with the acquired immunodeficiency syndrome (AIDS) or prodromal AIDS are described. A high incidence (38 per cent) of nonparatrabecular lymphohistiocytic infiltrations containing irregular small lymphocytes was observed, as well as the presence of diffuse bone marrow damage with plasmacytosis (22 per cent), decreased or absent stainable iron (50 per cent), and histologically identifiable pathogenic organisms (6 per cent). Morphologically, the lymphohistiocytic infiltrations are indistinguishable from bone marrow involvement by peripheral T-cell lymphoma, which may cause confusion, especially when a concurrent lymph node biopsy is difficult to interpret. On deeper sectioning, a specimen from one patient assumed a more granulomatous appearance. Specimens from two patients with small, poorly formed noncaseating granulomas contained demonstrable organisms.

Hypercalcemia in a 79-Year-Old Woman

2. The causes of hypercalcemia are numerous and before undertaking a full workup, it is recommended to make sure that hypercalcemia truly exists and is not the result of a false positive laboratory test, hemoconcentration of the blood sample, or a secondary occurrence due to an increased serum total protein and albumin concentration. Hypercalcemia can occur due to common (accounting for approximately 90% of all cases), uncommon, and rare causes [T2]. Hypercalcemia secondary to hyperparathyroidism is most often a chronic disorder in which clinical manifestations develop only after many months, if not years. Hypercalcemia can also be an early manifestation of a malignancy (ie, “hypercalcemia of malignancy”), which is the second most common cause of hypercalcemia in adults. Primary hyperparathyroidism and malignancies account for close to 90% of all cases of hypercalcemia.1 Primary hyperparathyroidism is most commonly associated with a solitary adenoma affecting a single parathyroid gland; however, involvement of more than one parathyroid gland, a rare event, has been reported.2 Hereditary hyperparathyroidism is usually part of a multiple endocrine neoplasia (MEN) syndrome, type 1 or 2A. Hypercalcemia of Principal Laboratory Findings

Anemia and Severe Erythrocytic Morphologic Abnormalities in Two Young Patients

Possible Answers: 1. Patient #1. Markedly decreased hemoglobin (Hb) and hematocrit; low MCV and MCH; decreased WBC count with decreased neutrophils and increased lymphocytes; markedly increased nucleated RBCs with marked reticulocytosis; markedly abnormal RBC morphology, including the presence of target cells; decreased RBC osmotic fragility [T1] and [I1]; and, hypergammaglobulinemia. Patient #2. Markedly decreased hemoglobin and hematocrit; low-normal MCV and MCH; increased WBC count with decreased neutrophils, increased bands; a few nucleated RBCs with marked reticulocytosis; and markedly abnormal RBC findings, including the presence of sickle cells [T2] and [I2]. 2. Microcytic-hypochromic anemia (Patient #1; low hemoglobin, hematocrit, MCV, and MCH) and normocyticnormochromic anemia (Patient #2; low hemoglobin and hematocrit with low-normal MCV and MCH). Moreover, both patients demonstrated pallor and parasternal systolic murmurs, findings consistent with anemia. Nucleated red blood cells (RBCs) were observed on the peripheral blood smear from both of these patients. Circulating nucleated RBCs are abnormal except in the neonatal period and often enter the circulation during periods of bone marrow stress caused by severe hemolysis. Both patients had an elevated reticulocyte count (reticulocytosis), which is a reliable indicator of accelerated erythropoiesis, especially when hemolysis is severe enough to produce anemia. White blood cell abnormalities: Patient # 1 had leukopenia and neutropenia. Common causes of non-neoplastic neutropenia include therapeutic drugs, such as analgesics and antibiotics, certain infections (our patient had a clinically undefined febrile illness), and autoimmune disease. Patient #2 had increased neutrophilic bands in the context of an increased WBC count. This is probably a non-specific finding, but it could be an indication of an early left-shift as seen Principal Laboratory Findings: Patient #1