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Large B-cell lymphoma mimicking iliopsoas abscess following open revision of proximal femur infected non-union: a case report.

McCammon J, Mascarenhas R, Monument MJ, Elyousfi A, Pilkey B - BMC Res Notes (2014)

Bottom Line: Extranodal presentation of lymphoma is a rare occurrence.We present a case report of a large extranodal B-cell lymphoma mimicking a postoperative abscess following surgery for an infected proximal femur nonunion in an 80-year-old Caucasian male of Italian descent.This case highlights the need to consider malignancy in revision surgery, careful examination of operative specimens and the need for further understanding of the role of metal implants in chronic antigen stimulation.

View Article: PubMed Central - HTML - PubMed

Affiliation: Section of Orthopedic Surgery, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada. j_mccammon@hotmail.com.

ABSTRACT

Background: Extranodal presentation of lymphoma is a rare occurrence. It has been postulated that chronic antigen stimulation may predispose a patient to the development of lymphoma.

Case presentation: We present a case report of a large extranodal B-cell lymphoma mimicking a postoperative abscess following surgery for an infected proximal femur nonunion in an 80-year-old Caucasian male of Italian descent.

Conclusions: This case highlights the need to consider malignancy in revision surgery, careful examination of operative specimens and the need for further understanding of the role of metal implants in chronic antigen stimulation.

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Related in: MedlinePlus

Intra-operative specimen. These samples were taken at the time of initial incision and drainage. Cultures were negative while pathology came back positive for B-cell lymphoma.
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Figure 3: Intra-operative specimen. These samples were taken at the time of initial incision and drainage. Cultures were negative while pathology came back positive for B-cell lymphoma.

Mentions: The patient’s surgical history was significant for six previous operations for a left intertrochanteric femoral fracture complicated by an infected non-union. An infectious diagnosis had been proven with Staphylococcus aureus cultured from previous operations. His most recent surgery occurred one month prior to his presentation to the emergency room and involved removal of a left trochanteric fixation nail and excision of a pseudoarthrosis, followed by an osteotomy of the left proximal femur nonunion and fixation with a proximal femoral locking plate (Figure 1). No complications were encountered during that surgery or afterwards, and the patient had been discharged home several days after surgery with instructions to avoid bearing weight on the left leg.On physical examination, the patient was hemodynamically stable and afebrile. A general physical examination, including lymph nodes, was unremarkable. Inspection revealed pronounced firm swelling of the left thigh with slight erythema. The surgical incision on the lateral aspect of the left thigh was clean and dry. There was slight tenderness to palpation over the swollen area and left hip and knee range of motion was restricted secondary to pain in the left thigh. The patient was neurovascularly intact in his left leg. Lab results, including erythrocyte sedimentation rate, C-reactive protein, white blood cell count, and hemoglobin levels were all within normal range. Left hip radiographs showed only generalized soft tissue swelling of the left thigh with no signs of hardware failure. Computed tomography (CT) scanning of the pelvis and left thigh was suggestive of the diagnosis of a psoas abscess (Figure 2A, B).After obtaining blood and urine cultures, the patient was admitted to hospital and broad-spectrum intravenous antibiotics were started based on recommendations from a surgical infectious disease specialist. The patient underwent incision and drainage for the left thigh abscess that same day using the previous lateral hip incision. No pus was noted intraoperatively, but a collection of thick white gelatinous tissue was noted underneath the muscle fascia of the left thigh anterior compartment and was observed to extend medially and laterally (Figure 3). Tissue specimens were sent for gram stain, aerobic and anaerobic cultures, acid fast testing, fungal cultures and cytology. The wound was then irrigated with normal saline and antibiotic beads and a hemovac drain were placed inside the wound. Intravenous antibiotics were resumed post-operatively and all cultures were negative. When swelling did not resolve within a few days after surgery, a repeat CT of the pelvis showed residual features of the presumed iliopsoas abscess extending into the left thigh. On postoperative day two, the patient underwent a second look incision and drainage through a combined ilioinguinal and lateral hip approach. A mass was noted close to the left iliac wing encasing the left femoral nerve. The femoral nerve was freed from the lesion without complication and the mass was then removed, debulked, and sent for frozen section. The frozen section revealed acute and chronic inflammation. The remaining tissue was sent for microbiology and histopathology. The wound was irrigated with normal saline and a hemovac drain was again placed before wound closure. Postoperatively, the patient was re-evaluated by the surgical infectious disease service, who proceeded to discontinue IV antibiotics and advised initiating anti-tuberculosis therapy. This decision was based on a diagnosis of exclusion, given the negative bacterial cultures, the anatomic site of the abscess and the gross pathological features of the biopsied tissue. All screening tests for tuberculosis were negative. CT scans of the chest and abdomen were performed as part of a metastatic work up, but revealed only a large right-sided kidney cyst. The patient improved and was discharged home with oral anti-tuberculosis therapy to be taken until definitive pathology results were available. Two weeks later, final pathology reports supported the diagnosis of a diffuse large B-cell lymphoma. Anti-tuberculosis drugs were discontinued and a medical oncologist was consulted to initiate chemotherapy.


Large B-cell lymphoma mimicking iliopsoas abscess following open revision of proximal femur infected non-union: a case report.

McCammon J, Mascarenhas R, Monument MJ, Elyousfi A, Pilkey B - BMC Res Notes (2014)

Intra-operative specimen. These samples were taken at the time of initial incision and drainage. Cultures were negative while pathology came back positive for B-cell lymphoma.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4120726&req=5

Figure 3: Intra-operative specimen. These samples were taken at the time of initial incision and drainage. Cultures were negative while pathology came back positive for B-cell lymphoma.
Mentions: The patient’s surgical history was significant for six previous operations for a left intertrochanteric femoral fracture complicated by an infected non-union. An infectious diagnosis had been proven with Staphylococcus aureus cultured from previous operations. His most recent surgery occurred one month prior to his presentation to the emergency room and involved removal of a left trochanteric fixation nail and excision of a pseudoarthrosis, followed by an osteotomy of the left proximal femur nonunion and fixation with a proximal femoral locking plate (Figure 1). No complications were encountered during that surgery or afterwards, and the patient had been discharged home several days after surgery with instructions to avoid bearing weight on the left leg.On physical examination, the patient was hemodynamically stable and afebrile. A general physical examination, including lymph nodes, was unremarkable. Inspection revealed pronounced firm swelling of the left thigh with slight erythema. The surgical incision on the lateral aspect of the left thigh was clean and dry. There was slight tenderness to palpation over the swollen area and left hip and knee range of motion was restricted secondary to pain in the left thigh. The patient was neurovascularly intact in his left leg. Lab results, including erythrocyte sedimentation rate, C-reactive protein, white blood cell count, and hemoglobin levels were all within normal range. Left hip radiographs showed only generalized soft tissue swelling of the left thigh with no signs of hardware failure. Computed tomography (CT) scanning of the pelvis and left thigh was suggestive of the diagnosis of a psoas abscess (Figure 2A, B).After obtaining blood and urine cultures, the patient was admitted to hospital and broad-spectrum intravenous antibiotics were started based on recommendations from a surgical infectious disease specialist. The patient underwent incision and drainage for the left thigh abscess that same day using the previous lateral hip incision. No pus was noted intraoperatively, but a collection of thick white gelatinous tissue was noted underneath the muscle fascia of the left thigh anterior compartment and was observed to extend medially and laterally (Figure 3). Tissue specimens were sent for gram stain, aerobic and anaerobic cultures, acid fast testing, fungal cultures and cytology. The wound was then irrigated with normal saline and antibiotic beads and a hemovac drain were placed inside the wound. Intravenous antibiotics were resumed post-operatively and all cultures were negative. When swelling did not resolve within a few days after surgery, a repeat CT of the pelvis showed residual features of the presumed iliopsoas abscess extending into the left thigh. On postoperative day two, the patient underwent a second look incision and drainage through a combined ilioinguinal and lateral hip approach. A mass was noted close to the left iliac wing encasing the left femoral nerve. The femoral nerve was freed from the lesion without complication and the mass was then removed, debulked, and sent for frozen section. The frozen section revealed acute and chronic inflammation. The remaining tissue was sent for microbiology and histopathology. The wound was irrigated with normal saline and a hemovac drain was again placed before wound closure. Postoperatively, the patient was re-evaluated by the surgical infectious disease service, who proceeded to discontinue IV antibiotics and advised initiating anti-tuberculosis therapy. This decision was based on a diagnosis of exclusion, given the negative bacterial cultures, the anatomic site of the abscess and the gross pathological features of the biopsied tissue. All screening tests for tuberculosis were negative. CT scans of the chest and abdomen were performed as part of a metastatic work up, but revealed only a large right-sided kidney cyst. The patient improved and was discharged home with oral anti-tuberculosis therapy to be taken until definitive pathology results were available. Two weeks later, final pathology reports supported the diagnosis of a diffuse large B-cell lymphoma. Anti-tuberculosis drugs were discontinued and a medical oncologist was consulted to initiate chemotherapy.

Bottom Line: Extranodal presentation of lymphoma is a rare occurrence.We present a case report of a large extranodal B-cell lymphoma mimicking a postoperative abscess following surgery for an infected proximal femur nonunion in an 80-year-old Caucasian male of Italian descent.This case highlights the need to consider malignancy in revision surgery, careful examination of operative specimens and the need for further understanding of the role of metal implants in chronic antigen stimulation.

View Article: PubMed Central - HTML - PubMed

Affiliation: Section of Orthopedic Surgery, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada. j_mccammon@hotmail.com.

ABSTRACT

Background: Extranodal presentation of lymphoma is a rare occurrence. It has been postulated that chronic antigen stimulation may predispose a patient to the development of lymphoma.

Case presentation: We present a case report of a large extranodal B-cell lymphoma mimicking a postoperative abscess following surgery for an infected proximal femur nonunion in an 80-year-old Caucasian male of Italian descent.

Conclusions: This case highlights the need to consider malignancy in revision surgery, careful examination of operative specimens and the need for further understanding of the role of metal implants in chronic antigen stimulation.

Show MeSH
Related in: MedlinePlus