CASE REPORT

A patient, EP, female, 6 years and 11 months of age, weighing 15 kg, with a
body height of 97 cm, was admitted in to Haji Adam Malik General Hospital on
February 9th, 2010 at 03:10 pm with the main complaint: bulging on the neck. The
patient was a former patient in the non-infectious unit of the pediatrics Department,
Haji Adam Malik General Hospital; was diagnosed with Non Hodgkins Lymphoma
and has undergone chemotherapy. The patient was readmitted to continue the therapy
protocol. Fever, vomit, and seizures were not confirmed. Paleness of the face was
confirmed. Defecation and urination was confirmed.
History of spontaneous delivery was confirmed, aided by a midwife, full term
with spontaneous cryning.
On Physical Examination, the following findings were confirmed.
Body Weight was 15 kg, body height was 97 cm, and body temperature 36,40C.
Level of consciousness

: Aware
Dyspnoe, cyanosis, edema, ichteric eyes, and anemia
were not confirmed.

Head

: Eyes: Light reflexes +/+,Pale lower eyelids were confirmed.

Mouth/nose/ears: Within normal limits.

Neck

: Enlargement was confirmed. (+ mass)

Chest

: Symmetrical fusiformic, HR : 80 bpm, regularly, murmurs (-)

RR : 24 tpm, regularly, rales ()

Abdomen

: Soepel, without enlargement.

H/L : In palpable

Extremities

: Pulse 80 bpm, regularly, Pressure/Volume was adequate.

Genitalia

: Female, there were no abnormalities present.

Differential diagnosis :
Working Diagnosis : Non Hodgkins Lymphoma.

10

Further Examinations :
-

CBC

PRC Transfusion, if Hb declines.

Medication :
-

Vincristine 1,5 m/m2 (IV)

MTX + Ara-C + Dexa (IT)

Oral Prednisone 4,8 mg/m2.

Lab Findings
February 9th 2010
-

WBC : 2.1 x 103/uL

Hb

: 10.3 g/dL

PLT

: 608 x 103/uL

Daily Follow Up
February 10th 2010
S

: Pale face was confirmed.

: Level of consciousness: Aware, T : 36.4oC.

Head

: Eyes: +/+ Light reflexes, +/+ Right/Left Isochoric pupil, pale

lower eyelids were confirmed, ears/nose/mouth: in normal limits.

Neck

: Mass was present, Lymph node enlargement was not

confirmed.
Chest

: Symmetrical fusiformic, retraction was not confirmed.

HR: 88 bpm, regularly, murmurs (-)
RR: 24 tpm, regularly, rales (-)

Abdomen

: Soepel, Normal peristaltic was confirmed, H/L: in palpable.

Extremities : pulse 80 bpm, regularly, Pressure/Volume was adequate.

A

: Non-Hodgkins Lymphoma.

11

: 1. Vincristine 1.5 mg/m2 (IV)

2. MTX + Ara-C + Dexa (IT)
3. Oral Prednisone 40 mg/m2.

February 10th 2010 (Afternoon)

S

: Pale face was confirmed.

: Level of consciousness: Aware, T : 36.2oC, BW: 15 kg, BH: 97 cm,

BW/BH: 107%, BSA: 0,65 m2.
Head

: Eyes: +/+ Light reflexes, +/+ Right/Left Isochoric pupil, pale

lower eyelids were confirmed, ears/nose/mouth: in normal limits.

Neck

: Mass was present, Lymph node enlargement was not

confirmed.
Chest

: Symmetrical fusiformic, retraction was not confirmed.

HR: 120 bpm, regularly, murmurs (-)
RR: 30 tpm, regularly, rales (-)

Abdomen

: Soepel, Normal peristaltic was confirmed, H/L: in palpable.

Extremities : pulse 120 bpm, regularly, Pressure/Volume was adequate.

A

: Non-Hodgkins Lymphoma.

: 1. Vincristine 1.5 mg/m2 (IV)

: 1.5x0,65 = 0.975 mg/x/IV

2. MTX IT

: 10mg/time/IT.

3. Ara-C

: 30mg/time/IT.

4. Dexa (IT)

: 1,0mg/time/IT.

February 11th 2010

S

: Pale face, fever, and bleeding were not confirmed.

: Level of consciousness: Aware, T : 36.2oC, BW: 15 kg, BH: 97 cm,

BW/BH: 107%, BSA: 0,65 m2.
Head

: Eyes: +/+ Light reflexes, +/+ Right/Left Isochoric pupil, pale

lower eyelids were confirmed, ears/nose/mouth: in normal limits.

12

Neck

: Mass was present, Lymph node enlargement was not

confirmed.
Chest

: Symmetrical fusiformic, retraction was not confirmed.

HR: 120 bpm, regularly, murmurs (-)
RR: 30 tpm, regularly, rales (-)

Abdomen

: Soepel, Normal peristaltic was confirmed, H/L: in palpable.

Extremities : pulse 120 bpm, regularly, Pressure/Volume was adequate.

A

: Non-Hodgkins Lymphoma.

: 1. Vincristine 1.5 mg/m2 (IV)

: 1.5x0,65 = 0.975 mg/x/IV

2. MTX IT

: 10mg/time/IT.

3. Ara-C

: 30mg/time/IT.

4. Dexa (IT)

: 1,0mg/time/IT.

3. Oral Prednisone 40 mg/m2

Lab Findings
February 11th 2010
-

Hb

: 10.3 g/dL

Erytrocytes

: 4.28 x 106 u/L

Leucocytes

: 4.5 x 103 u/L

Trombocytes

: 293 x 103 u/L

Haematocrytes

: 32.3

MCV

: 74 fls

MCH

: 22.7 pg

MCHC

: 35,7

February 12th 2010

The patient was discharged to return again on February 17th 2010 for medication.

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A patient, EP, female, 6 years and 11 months of age, weighing 15 kg, with a
body height of 103 cm, was admitted in to Haji Adam Malik General Hospital on
February 18th, 2010 at 01:00 pm with the main complaint: bulging on the neck. The
patient was a former patient in the non-infectious unit of the pediatrics Department,
Haji Adam Malik General Hospital; was diagnosed with Non Hodgkins Lymphoma
and has undergone routine chemotherapy consisting of Vincristine, CPA, MTX+Ara
C+Dexa (IT). The patient was readmitted to continue the therapy protocol. Fever was
not confirmed. Cough and shortness of breath was not confirmed.
On Physical Examination, the following findings were confirmed.
Body Weight was 15 kg, body height was 103 cm, and body temperature 37,00C.
Level of consciousness

: Aware
Dyspnoe, cyanosis, edema, ichteric eyes, and anemia
were not confirmed.

Head

: Eyes: Light reflexes +/+, Pale lower eyelids were not confirmed.
Right/Left Isochoric pupil.
Mouth/nose/ears: Within normal limits.

Neck

: Mass was confirmed on the right side of the neck with a firm
consistency. Multiple bulging were confirmed.

Chest

: Symmetrical fusiformic, without retraction.

HR : 94 bpm, regularly, murmurs (-)
RR : 20 tpm, regularly, rales (-/-)

Abdomen

: Soepel, normal peristaltic.

H/L : In palpable

Extremities

: Pulse 94 bpm, regularly, Pressure/Volume was adequate.

Genitalia

: Female, there were no abnormalities present.

Differential diagnosis :
Working Diagnosis : Non Hodgkins Lymphoma.

14

Medication :
Chemotherapy
-

Vincristine

1,5 mg/m2 (IV)

CPA

1200/ml

MTX + Ara-C + Dexa (IT)

Cotrimoxazole

2x240mg

Oral Prednisone

2-2-1

Usual meal diets

1250 kkal with 30gr of protein.

Lab Findings
February 17th 2010
Liver Profile
-

Total Billirubin

0.324 mg/dl

Direct Billirubin

0.236 mg/dl

SGOT (AST)

25.2 u/L

SGPT (ALT)

25.7 u/L

Alkaline Phosphatase :

108

u/L

Kidney Profile
-

Ureum

23.9 mg/dl

Creatinine

0,39 mg/dl

Uric Acid

3.9

mg/dl

Complete Blood Count

-

WBC

11.54 x 103/uL

Neutrophil

7.70 x 103/m

Lymphocytes

1.95 x 103/uL

Monocytes

1.6 x 103/uL

Eosinophil

400 x 103/uL

Basophil

0.03 x 103/uL

RBC

3.89 x 106/uL

15

Hb

10.6 g/dL

Hct

33.1 %

MCH

27.2 pg

MCV

85.1 fl

MCHC

32.0 g/dl.

PLT

462 x 103/uL

Daily Follow Up
February 18th 2010
S

: fever was not confirmed.

: Level of consciousness: Aware, T : 36.8oC, BW: 15 kg, BH: 97 cm,

BSA: 0,65 m2.
Head

: Eyes: +/+ Light reflexes, +/+ Right/Left Isochoric pupil, pale

lower eyelids were not confirmed, ears/nose/mouth: in normal limits.

Neck

: Mass was present on the right side with a firm consistency.

Multiple bulging were confirmed. Lymph node enlargement was not

confirmed.
Chest

: Symmetrical fusiformic, retraction was not confirmed.

HR: 94 bpm, regularly, murmurs (-)
RR: 20 tpm, regularly, rales (-)

Abdomen

: Soepel, Normal peristaltic was confirmed, H/L: in palpable.

Extremities : pulse 94 bpm, regularly, Pressure/Volume was adequate.

A

: Non-Hodgkins Lymphoma.

: Chemotherapy
1.

Vincristine

1.5 mg/m2 (IV)

2.

CPA

1200/m2

3.

MTX IT + AraC + Dexa

Cotrimoxazole

2x240 mg

Prednisone

2-2-1

Usual food Diet

1250 kcal with 30 gr protein

16

February 19th 2010

S

: fever was not confirmed.

: Level of consciousness: Aware, T : 36.8oC, BW: 15 kg, BH: 97 cm,

BSA: 0,65 m2. Anemia, dyspnoe, and ichteric were not confirmed.
Head

: Eyes: +/+ Light reflexes, +/+ Right/Left Isochoric pupil, pale

lower eyelids were not confirmed, ears/nose/mouth: in normal limits.

Neck

: Mass was present on the right side with a firm consistency.

Multiple bulging were confirmed. Lymph node enlargement was not

confirmed.
Chest

: Symmetrical fusiformic, retraction was not confirmed.

HR: 120 bpm, regularly, murmurs (-)
RR: 20 tpm, regularly, rales (-)

Abdomen

: Soepel, Normal peristaltic was confirmed, H/L: in palpable.

Extremities : pulse 120 bpm, regularly, Pressure/Volume was adequate.

A

: Non-Hodgkins Lymphoma.

: IVFD D 5%, NaCl 0.45% 20 drops/minute

Chemotherapy
4.

Vincristine

1.5 mg/m2 (IV)

5.

CPA

1200/m2

6.

MTX IT + AraC + Dexa

Cotrimoxazole

2x240 mg (3 times a week)

Prednisone

2-2-1

Usual food Diet

1250 kcal with 30 gr protein

February 20th 2010

S

: fever was not confirmed.

: Level of consciousness: Aware, T : 36.8oC, BW: 15 kg, BH: 97 cm,

BSA: 0,65 m2.

17

Head

: Eyes: +/+ Light reflexes, +/+ Right/Left Isochoric pupil, pale

lower eyelids were not confirmed, ears/nose/mouth: in normal limits.

Neck

: Mass was present on the right side with a firm consistency.

Multiple bulging were confirmed. Lymph node enlargement was not

confirmed.
Chest

: Symmetrical fusiformic, retraction was not confirmed.

HR: 110 bpm, regularly, murmurs (-)
RR: 20 tpm, regularly, rales (-)

Abdomen

: Soepel, Normal peristaltic was confirmed, H/L: in palpable.

Extremities : pulse 110 bpm, regularly, Pressure/Volume was adequate.

A

: Non-Hodgkins Lymphoma.

: Chemotherapy
1. Cyclophosphamide

780 mg/IV

Cotrimoxazole

2x240 mg

Prednisone

2-2-1 (28/1-2010 4/3-2010)

Usual food Diet

1250 kcal with 30 gr protein

Discussion
Pediatric lymphoma accounts for 10% of cases of malignant disease among
children.. Approximately 60% of cases of pediatric lymphoma are non-Hodgkin
lymphoma; the others are Hodgkin disease. Unlike Hodgkin disease, non-Hodgkin
lymphoma can occur even among infants, and the incidence rises steadily with
increasing age. The male to female ratio is 3:1. As many as 10% of children with
congenital or acquired immunosuppression have non-Hodgkin lymphoma, the highest
incidence being in ataxia-telangectasia and Wiskott-Aldrich syndrome. In this case
the patient was 6 years of age, confirming the fact that NHL incidence rises steadily
after infancy. The possibility of being associated with Wiskott-Aldrich syndrome was
low, due to the fact that WAS always causes persistent thrombocytopenia and is an Xlinked recessive genetic condition; therefore, this disorder is found almost exclusively
in boys.

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In epidemiologic studies, non-Hodgkin's lymphoma (NHL) has been

associated with exposure to chemicals such as phenoxyacetic acids; chlorophenols;
dioxins; organic solvents including benzene, polychlorinated biphenyls, chlordanes;
and immunosuppressive drugs. Experimental evidence and clinical observations
indicate that these chemicals may impair the immune system. Also, certain viruses
have been suggested to be of etiologic significance for NHL. In some cases of NHL
the

common

mechanism

for

all

these

agents

and

conditions

may

be

immunosuppression, possibly in combination with viruses. When the parents were

questioned on a history taking, these etiologic possibilities were not confirmed, thus
delaying the determination of a certain cause on this patient.
Based on the St. Jude Staging System for Childhood Non-Hodgkin
Lymphoma, this patient is categorized as stage 2 due to the presence of several single
(extranodal) tumors without regional node involvement on the same side of the
diaphragm.
The four major pathological subtypes of childhood and adolescent NHL are
Burkitt lymphoma (BL), constituting 40% of NHL; lymphoblastic lymphoma (LL),
accounting for 30%; diffuse large B-cell lymphoma (DLBCL), constituting 20%; and
anaplastic large cell lymphoma (ALCL), accounting for 10%. The pathological
subtype of this patient was unclear due to the fact that the patients parents did not
enclose the FNAB results that had been conducted. Even though, it quite possible to
classify this patients NHL as a BL because BL commonly presents with head and
neck (endemic type) disease.
The Essentials of diagnosis and Typical Features of Non Hodgkins
Lymphoma are as follows.
Cough, dyspnea, orthopnea, swelling of the face, lymphadenopathy, mediastinal
mass, pleural effusion.
Abdominal pain, abdominal distention, vomiting, constipation, abdominal mass,
ascites, hepatosplenomegaly.
Adenopathy, fevers, neurologic deficit, skin lesions.
The patient herself only was only presented with fever and pale face.

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Types of Biopsy conducted to confirm the diagnosis of NHL are as follows.

Fine needle aspiration (FNA) biopsy uses a very thin, hollow needle that is
attached to a syringe. If the enlarged lymph node is palpable (can be felt) and
near the skin's surface, the needle is inserted into the swollen lump. It is then
pushed back and forth to free some cells, which are aspirated (drawn up) into
the syringe and are smeared on a glass slide for analysis. If the suspicious
nodes or tissues are deep within the body (e.g., abdominal nodes, thymus), the
needle may be guided while it is viewed on a CT (computed tomography)
scan.
FNA can distinguish noncancerous conditions, like infections, from NHLs or
other cancers. FNA also is useful for staging, or determining the extent, of
disease, and for monitoring recurrence, or return of cancer. But, because of
small sample sizes and lack of information about lymph node structure, FNA
often is inadequate for the initial diagnosis of HD or NHL. In such cases,
larger tissue samples are obtained by surgical biopsy.

Large needle/Core biopsy uses a large-bore needle to obtain a small tissue

sample for analysis. Core biopsy has limited role in the diagnosis of
lymphoma and is reserved for those patients who are unable to tolerate an
invasive surgical procedure. Both FNA and core biopsy procedures may be
guided by CT, ultrasound, or other imaging techniques.

Surgical biopsy refers to both incisional (cutting into) and excisional (cutting
away) procedures. If a tumor mass is large and only a tiny piece of it is
removed for examination, the procedure is called an incisional biopsy.
Incisional biopsy has, in large part, been replaced by needle biopsy; needle
biopsy is less time-consuming and less prone to infection and it produces less
scarring.
If the tumor mass is small and it is completely removed by biopsy, the
procedure is called an excisional biopsy. Excisional biopsy usually is

20

performed if a physician suspects that a lump is not cancerous (benign). Local

anesthesia is used if the node is located near the skin's surface and the child or
adult is cooperative; however, deeper nodes (e.g., in the chest or abdomen)
require general anesthesia.
In this patient, a FNAB procedure was conducted, although the parents did not
enclose the results on returning to the hospital for continuation of the patients
chemotherapy.
Based on the Chemotherapy guidelines, the primary modality of treatment for
childhood and adolescent NHL is multiagent systemic chemotherapy and intrathecal
chemotherapy. Specific treatment for localized and advanced disease is similar for BL
and DLBCL. Localized BL and DLBCL require 6 wk to 6 mo of multiagent
chemotherapy consisting of COMP (cyclophosphamide, vincristine, methotrexate, 6mercaptopurine and prednisone). Intrathecal chemotherapy is administered to
moderate to advanced disease in all subtypes of childhood and adolescent NHL and
may include intrathecal methotrexate, hydrocortisone, or Ara-C. In this case,
chemotherapy agents such as vincristine, Cyclophosphamide, MTX + Ara C + Dexa
(IT), and Prednisone were administered, suitable with the chemotherapy protocol for
stage II Non-Hodgkins Lymphoma.
Localized Burkitt and localized large cell lymphoma have a cure rate of 90%
with as little as 6 weeks of chemotherapy. the event-free survival rate for advanced
Burkitt disease and B-cell ALL is more than 80%. Most relapses occur within the first
8 months after diagnosis. Patients with Burkitt disease who survive disease free for
10 months are likely to be cured. Both the German (BFM) and French (SFOP) study
groups have obtained event-free survival rates of more than 80% for advanced stage
B-cell large cell non-Hodgkin lymphoma using the same short duration, intensive
protocol as for Burkitt disease. Based on the fact above, the prognosis of this patient
is good.

21