31-year-old male with history of polysubstance abuse and intravenous drug use presented with 8 months of chronic pain in his back, and 3 weeks of pain in his right hip rendering patient non weight bearing and with complaints of impotence. Patient reported a history of 20 pound unintentional weight loss over the last year. He denied fevers, chills, lymphadenopathy or night sweats. Urine Drug Screen was positive for benzodiazepines, opiates, amphetamines and cannabis. Plain films revealed sclerotic lesions. Computed Tomography (CT) revealed multifocal permeative osseous destruction of the right iliac bone, right inferior and superior pubic rami, right acetabulum and proximal femur with associated large soft tissue component involving the right iliac bone lesion. Bone scans revealed innumerable boney lesions of the axial skeleton.
Patient had no evidence of renal dysfunction as well as no anemia on admission. He was HIV negative with a negative hepatitis panel. Patient had mild elevation of WBC, and blood cultures grew Methicillin sensitive staph aureus (MSSA) complicating patients course.
A core needle biopsy of the soft tissue mass of the right iliac crest was obtained and sent for evaluation. The bone marrow revealed neoplastic cells positive for CD20, CD10 AND BCL-6. It showed sheets of large CD20+ B-cells with no follicular dendritic cell meshwork seen. These findings being consistent with the pathological presentation of diffuse large B-cell lymphoma (DLBCL).
Patient was initiated on standard chemotherapy with R-CHOP every 3 weeks, likely for 4-6 cycles and treated with IV antibiotics for his bacteremia.
Discussion:
Patient was diagnosed with Stage IV primary diffuse large B cell lymphoma of the bone which is a rare disease, occurring slightly more frequently in males than females (1.2 to 1.8) with a median age for presentation being over 60. Incidence of primary bone disease is less than 2 percent of all lymphomas in adults, accounting for 3-7 percent of primary bone tumors, and 3-5 percent for non Hodgkins lymphomas that occur extranodally. Primary lymphoma of the bone will often present as pain that occurs without antecedent trauma which is unrelieved by rest. Often, in health care settings, opiate addicts malingering for pain medications will present similarly. Patients with DLBCL often present with “B symptoms” including lymphadenopathy, night sweats, and weight loss. Rarely, they can present with primary bone lesions that can present similarly to sarcomas.
Conclusions:
Diffuse B cell Lymphoma is a lymphoma of abnormal B cell lymphocytes that typically grow in the lymph nodes. Most of the time they develop in a lymph node, however approximately 40 percent of cases arise extranodally. These most commonly occur in the gastrointestinal tract or stomach. Ewing sarcoma is a tumor that most often arises in the long bones of the extremities as well as the bones of the pelvis. Patients typically present with pain and swelling over the course of a few weeks to months. A soft tissue mass can sometimes be appreciable next to a bone. As hospitalists, it is important to not allow a patients past drug seeking behaviors cloud a thorough investigation of patients complaint as it may be revealing of significant life threatening disease.