Angioimmunoblastic Lymphoma With Proliferative Glomerulonephritis: A Rare Association

IntroductionAngioimmunoblastic T-cell lymphoma (AILT) is a subtype of peripheral T-cell lymphomas characterized by a polymorphous infiltrate involving lymph nodes, with a prominent proliferation of high endothelial venules and follicular dendritic cells along with systemic disease. It accounts for only 1%-2% of non-Hodgkin lymphomas. It usually involves peripheral lymph nodes, liver, spleen, bone marrow, and skin. Proliferative glomerulonephritis with AILT is extremely rare and is reported in only 5 cases in the literature. We describe a unique case of proliferative glomerulonephritis without immune deposits in a patient with AILT.Patients and MethodsA 68-year-old male presented with complaints of shortness of breath, fever, and weakness since 3 months. Physical examination revealed generalized lymphadenopathy with multiple, nontender, mobile lymph nodes with average size between 2-5 cm and hepatosplenomegaly. 1+ pitting edema was noted on the lower extremities, and skin examination revealed evidence of generally distributed pigmented skin macules associated with itching. Patient clinical course was worsened by a progressive renal failure and nephrotic range proteinuria. Axillary lymph node biopsy revealed architectural effacement, vascular growth with monoclonal T-cell population with T-cell receptor gamma gene restriction consistent with angioimmunoblastic T-cell lymphoma. Kidney biopsy revealed proliferative glomerulonephritis with increased mesangial cellularity and endocapillary proliferation and mild interstitial fibrosis. Immunofluorescence showed focal 1+ C3 staining in the glomerular capillary walls and mesangium. There were no immune deposits on electron microscopy. Patient required 1 episode of dialysis with improvement in renal function. A single cycle of chemotherapy with the CHOP regimen (cyclophosphamide, doxorubicin, vincristine, and prednisone) was given. However, the patient developed neutropenic sepsis and died.ResultsThe occurrence of proliferative glomerulonephritis with AILT is extremely rare. Most of the cases described so far had immune deposits. Our case is unique since the kidney biopsy did not show any evidence of immune deposits at any site. Mechanisms proposed to explain the renal lesions in lymphoid malignancies include expression of tumor antigens, autologous nontumor antigens, viral or fetal antigens, immune complex deposition and disordered T-cell function.ConclusionIn our opinion, cell-mediated immune reaction and/or alternate complement pathway activation (as evidenced by focal C3 staining) might have contributed to the glomerulonephritis in this case. The number of cases with this presentation is very few and the optimum management is not known. This case adds to the literature and helps us in better understanding the disease.     

Lumbar microdiscectomy as a day-case procedure: Scope for improvement?

Background and purpose

There are no significant differences in outcomes between patients receiving inpatient and day-case lumbar microdiscectomy, but the latter is still underused in the NHS. Here we aimed to identify factors contributing to successful same-day discharge in day-case patients.

Sex Specific Seasonal Variation in Hematological and Serum Biochemical Indices of <Emphasis Type="Italic">Barilius bendelisis</Emphasis> from Central Himalaya,India

The study aimed to assess the effects of sex and season on hematological and serum biochemical indices of Barilius bendelisis. Hematological and biochemical results showed significant differences (p < 0.05) among seasons as well as between sexes. In summer, hemoglobin, hematocrit, erythrocyte and WBC number were highest and significantly (p < 0.05) different between sexes. Differential WBC count also showed marked seasonal variation but do not show any significant difference (p < 0.05) between male and female. Mean corpuscular volume and mean corpuscular hemoglobin was high in winter and low in summer. For males and females, mean corpuscular hemoglobin concentration was high in summer, rainy, and low in winter season. Cholesterol level and low-density lipids were high in autumn and low in spring. High-density lipids (HDL) and very low-density lipids (VLDL) also fluctuated in different seasons with maximum HDL in both sexes in autumn. Maximum VLDL for male was observed in summer and in spring for female. Triglycerides were high in autumn and summer and low in spring. Throughout winter the total protein, albumin and globulin levels were highest. Glucose level was higher in summer and autumn whereas, lower in winter in both male and female respectively. This study revealed that the variation in seasonal environmental parameters have direct effect on the health status of B. bendelisis. The baseline data generated in this study will serve as a tool for fish physiologists and pathologists in monitoring the stress, health and nutritional status of B. bendelisis under aquaculture production.     

The Effect of Packed Red Blood Cell Transfusion on Cerebral Oxygenation and Metabolism After Subarachnoid Hemorrhage

Background

Anemia adversely affects cerebral oxygenation and metabolism after subarachnoid hemorrhage (SAH) and is also associated with poor outcome. There is limited evidence to support the use of packed red blood cell (PRBC) transfusion to optimize brain homeostasis after SAH. The aim of this study was to investigate the effect of transfusion on cerebral oxygenation and metabolism in patients with SAH.

Methods

This was a prospective observational study in a neurological intensive care unit of a university hospital. Nineteen transfusions were studied in 15 consecutive patients with SAH that underwent multimodality monitoring (intracranial pressure, brain tissue oxygen, and cerebral microdialysis). Data were collected at baseline and for 12 h after transfusion. The relationship between hemoglobin (Hb) change and lactate/pyruvate ratio (LPR) orbrain tissue oxygen (PbtO₂) was tested using univariate and multivariable analyses.

Results

PRBC transfusion was administered on the median post-bleed day 8. The average Hb concentration at baseline was 8.1 g/dL and increased by 2.2 g/dL after transfusion. PbtO₂ increased between hours 2 and 4 post-transfusion and this increase was maintained until hour 10. LPR did not change significantly during the 12-h monitoring period. After adjusting for SpO₂, cerebral perfusion pressure, and LPR, the change in Hb concentration was independently and positively associated with a change in PbtO₂ (adjusted b estimate = 1.39 [95 % confidence interval 0.09–2.69]; P = 0.04). No relationship between the change in Hb concentration and LPR was found.

Conclusions

PRBC transfusion resulted in PbtO₂ improvement without a clear effect on cerebral metabolism prior to SAH.

     

Approach to a case of myeloneuropathy

Myeloneuropathy is a frequently encountered condition and often poses a diagnostic challenge. A variety of nutritional, toxic, metabolic, infective, inflammatory, and paraneoplastic disorders can present with myeloneuropathy. Deficiencies of vitamin B12, folic acid, copper, and vitamin E may lead to myeloneuropathy with a clinical picture of subacute combined degeneration of the spinal cord. Among infective causes, chikungunya virus has been shown to produce a syndrome similar to myeloneuropathy. Vacuolar myelopathy seen in human immunodeficiency virus (HIV) infection is clinically very similar to subacute combined degeneration. A paraneoplastic myeloneuropathy, an immune-mediated disorder associated with an underlying malignancy, may rarely be seen with breast cancer. Tropical myeloneuropathies are classified into two overlapping clinical entities — tropical ataxic neuropathy and tropical spastic paraparesis. Tropical spastic paraparesis, a chronic noncompressive myelopathy, has frequently been reported from South India. Establishing the correct diagnosis of myeloneuropathy is important because compressive myelopathies may pose diagnostic confusion. Magnetic resonance imaging (MRI) in subacute combined degeneration of the spinal cord typically reveals characteristic signal changes on T2-weighted images of the cervical spinal cord. Once the presence of myeloneuropathy is established, all these patients should be subjected to a battery of tests. Blood levels of vitamin B12, folic acid, vitamins A, D, E, and K, along with levels of iron, methylmalonic acid, homocysteine, and calcium should be assessed. The pattern of neurologic involvement and results obtained from a battery of biochemical tests often help in establishing the correct diagnosis.