Case Studies

 Case 6.6 Non-Hodgkin's lymphoma

A 59-year-old man presented with a gradually increasing lump in his right groin of 6 months duration, which he thought was a 'hernia'. This was a large inguinal lymph node. He had suffered repeated urethritis in the past. He had no other symptoms, but was found on examination to have splenomegaly (7cm below the costal margin) without hepatomegaly.

On investigation, his haemoglobin was low (118g/l) but his white-cell count and differential were normal. His ESR was 58mm/h and the lactate dehydrogenase level was also high. His serum immunoglobulins were all reduced: his IgG was 5.2g/l (NR 7.2-19.0g/l); IgA 0.3g/l (NR 0.8-5.0g/l); and IgM 0.3g/l (NR 0.5-2.0g/l). Serum electrophoresis showed no monoclonal bands. The lymph node was excised; light microscopy showed irregular follicles with mixtures of small and large cells throughout but no organized germinal centres. Reactive follicular hyperplasia was a possibility but immunophenotyping of tissue sections showed monoclonality, with strong cellular staining of the multiple follicle cells with anti-IgG and anti-k antisera. Normal interfollicular T-cell staining was present. This patient had a follicular type of non-Hodgkin's lymphoma.