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The n e w e ng l a n d j o u r na l of m e dic i n e

case records of the massachusetts general hospital

Founded by Richard C. Cabot


Nancy Lee Harris, m.d., Editor Eric S. Rosenberg, m.d., Associate Editor
Jo-Anne O. Shepard, m.d., Associate Editor Alice M. Cort, m.d., Associate Editor
Sally H. Ebeling, Assistant Editor Christine C. Peters, Assistant Editor

Case 13-2008: A 46-Year-Old Man with


Rheumatoid Arthritis and Lymphadenopathy
Nikhil C. Munshi, M.D., Subba Digumarthy, M.D., and Aliyah Rahemtullah, M.D.

Pr e sen tat ion of C a se

From the Boston Veterans Affairs Health- Viviany Taqueti (Harvard Medical School): A 46-year-old man was seen in the hema-
care System and the Jerome Lipper Cen- tology–oncology clinic of a cancer center affiliated with this hospital because of
ter for Multiple Myeloma, Dana–Farber
Cancer Institute (N.C.M.); the Depart- anorexia and generalized lymphadenopathy.
ments of Radiology (S.D.) and Pathology The patient had a history of rheumatoid arthritis but had been otherwise well
(A.R.), Massachusetts General Hospital; until 1 month earlier, when diffuse lymphadenopathy gradually developed in his
and the Departments of Medicine (N.C.M.),
Radiology (S.D.), and Pathology (A.R.), neck, axillae, and groin, associated with sore throat and loss of appetite but not
Harvard Medical School — all in Boston. with weight loss. Approximately 1 week before this evaluation, fatigue, nausea,
bloating, loose stools, and a cough productive of white sputum developed. On
N Engl J Med 2008;358:1838-48.
Copyright © 2008 Massachusetts Medical Society. examination by his primary care physician 5 days before this evaluation, the patient’s
blood pressure was 118/70 mm Hg, the pulse 108 beats per minute, the tempera-
ture 37.3°C, and the oxygen saturation 98% while he was breathing ambient air.
White lesions were present laterally on the tongue, and there were enlarged, tender
lymph nodes, up to 2 cm in diameter, in the right submandibular, bilateral anterior
cervical, left posterior cervical, and both axillary regions. The remainder of the
examination was normal. The results of laboratory tests are shown in Table 1. Oral
nystatin was prescribed. The patient returned the next day, with wheezing and
purulent nasal discharge; on examination, there was tenderness over the maxillary
sinuses and serous effusions behind the tympanic membranes. The lymphadenopa-
thy had decreased slightly. The chest was clear on auscultation. A chest radiograph
revealed prominence of the pulmonary hila and superior mediastinum, suggestive
of lymphadenopathy, and biapical pleural thickening and bibasilar parenchymal
scarring that were unchanged from a study 16 months earlier. Treatment with
levofloxacin was begun.
The next day, computed tomographic (CT) scanning of the chest, abdomen, and
pelvis after the intravenous administration of contrast material showed enlarged
lymph nodes, ranging from 5 mm to 2.5 cm in diameter, in the bilateral supracla-
vicular, axillary, hilar, internal and external iliac, and inguinal regions; the medias-
tinum; and the retroperitoneum. Some of the axillary lymph nodes contained lucent
centers, suggesting necrosis. There was basilar and biapical pulmonary fibrosis,
and two subpleural pulmonary nodules on the right side, each 9 mm in diameter,
were evident. A rounded density, 2.5 cm in diameter, was present posterior to the

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case records of the massachuset ts gener al hospital

stomach, and the colonic wall was thickened. The showed no evidence of an accessory spleen. The
patient was referred to a hematologist–oncologist. neutropenia was thought to be related to the pa-
The patient reported no shortness of breath or tient’s medications, and he was advised to discuss
chest pain. Rheumatoid arthritis had been diag- possible changes in therapy with his rheumatol­
nosed 31/2 years earlier, manifested as morning ogist.
stiffness, joint pain, and swelling mostly in the The patient had occasional gastroesophageal
hands and feet, decreased range of motion in the reflux that was relieved by pantoprazole. A tonsil-
hips and lumbar spine, and positive serologic lectomy had been performed in childhood. He
tests (Table 1). At the age of 18 years, the patient had no drug allergies. He had received pneumo-
had pain and swelling in the right elbow and coccal vaccine after the splenectomy. He was mar-
both ankles; juvenile rheumatoid arthritis was ried, had been monogamous with his wife for
diagnosed. The symptoms resolved spontaneously more than a decade, and did not smoke or drink
when the patient was in his early 20s. A diagno- alcohol. He worked as a painter and had not
sis of ankylosing spondylitis was also mentioned traveled recently. There was no family history of
to him, but he did not recall back pain, iritis, autoimmune disease or hematologic cancer. Med-
aphthous ulcers, dysuria, or rash. At the age of ications included hydroxychloroquine, lefluno-
32 years, an enlarged spleen (measuring 19 cm mide, meloxicam, pantoprazole, folic acid, and
in length by ultrasonography) had been found in­ levofloxacin; he had never received tumor necro-
cidentally during evaluation for acute cholecysti- sis factor antagonists.
tis; splenectomy and cholecystectomy were per- On examination, the blood pressure was
formed. On pathological examination, the spleen 120/60 mm Hg, and the weight 68.2 kg. There
weighed 400 g, with fibrocongestive changes and were enlarged, mobile, nontender lymph nodes in
reactive lymphoid hyperplasia. Pathological exam­ the cervical, supraclavicular, axillary, and ingui-
ination of a biopsy specimen of the bone marrow nal regions, which were larger on the left side
showed no abnormalities. than on the right; an axillary node on the left
Symptoms of rheumatoid arthritis were con- side was 4 cm in diameter. The remainder of the
trolled with prednisone, methotrexate, folic acid, examination was normal. The prothrombin time,
nonsteroidal antiinflammatory medications, and partial-thromboplastin time, and test results for
leflunomide. Nineteen months before this eval- lupus anticoagulant were normal.
uation, cutaneous lesions had developed on sun- One week later, a diagnostic procedure was
exposed areas; examination of a biopsy specimen performed.
showed changes consistent with subacute cutane-
ous lupus erythematosus. Methotrexate was dis- Differ en t i a l Di agnosis
continued, and hydroxychloroquine was added;
the skin lesions resolved. One year before this Dr. Nikhil C. Munshi: May we review the imaging
evaluation, corticosteroids were discontinued be- studies?
cause of recurrent oral candidiasis. Dr. Subba Digumarthy: Axial CT studies of the
Routine laboratory monitoring revealed fluctu- chest, abdomen, and pelvis performed after the
ating and intermittently low leukocyte counts intravenous administration of contrast material
(Table 1). Three months before this evaluation, show enlarged lymph nodes in the supraclavicu-
the patient had been referred to the hematolo- lar fossae, axillae, and mediastinum, as well as
gist–oncologist for evaluation of neutropenia. in the para-aortic, external iliac, and inguinal
Examination of a peripheral-blood smear revealed regions (Fig. 1A). Small areas of decreased en-
Howell–Jolly bodies; test results for antibodies to hancement in the center of some lymph nodes
the human immunodeficiency virus (HIV) and suggest necrosis. The spleen is absent. In the
hepatitis A, B, and C viruses were negative; serum splenectomy bed, there are surgical clips and an
levels of calcium, phosphorus, protein, and albu- enhancing soft-tissue nodule; the imaging fea-
min and tests of liver and renal function were tures are consistent with an accessory spleen
normal; other laboratory-test results from this (Fig. 1B).
earlier evaluation are shown in Table 1. Flow- There are multiple reticular opacities in the
cytometric analysis of peripheral-blood lympho- lung apexes, associated with architectural distor-
cytes was normal. A scan of the liver and spleen tion and mild bronchiectasis, and ground-glass

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Table 1. Laboratory Data.

1840
Reference Range
Analyte for Adults* 3.5 Yr Earlier 19 Mo Earlier 8 Mo Earlier 3 Mo Earlier 4 Days Earlier
Hematocrit (%) 41.0–53.0 40.3 42 42.9 44.5
Hemoglobin, whole blood (g/dl) 13.5–17.5 13.6 14.1 14.3 14.8
White-cell count (per mm3) 4000–11,000 5,200 2,900 3,600 8,800
Differential count (%)
Neutrophils 44–75 77 19 17 42
Band forms 0–10 0 4 21
Lymphocytes 15–45 10 47 62 16
Monocytes 0–15 12 34 14 16
Eosinophils 0–6 0 2 5
Basophils 0–2 1 0 0
The

Atypical lymphocytes 0 1
Erythrocyte sedimentation rate (mm/hr) 0–17 Normal 38 34
Platelet count (per mm3) 165,000–400,000 344,000 259,000 271,000
γ-Glutamyl transpeptidase (U/liter) 0–40 44
Lactate dehydrogenase (U/liter) 0–250 222
Herpes simplex virus
Type 1 IgG Positive
Type 1 IgM Negative
Type 2 IgG Negative
n e w e ng l a n d j o u r na l

Type 2 IgM Negative


of

Lyme IgG–IgM <0.75 (negative) <0.75 0.05


Monospot test for heterophile antibody Negative
Rheumatoid factor (IU/ml) <30.0 314 568

n engl j med 358;17  www.nejm.org  april 24, 2008


Autoantibodies
m e dic i n e

Antinuclear antibody Negative at 1:40 Positive at 1:1280, Positive at 1:320, Positive at 1:640,
speckled pattern speckled pattern speckled pattern
Anti–double-stranded DNA antibody (U) <25 3.0 Negative
Anti–Jo-1 antibody IgG (U) <20 5.6
Anti-La antibody (U) <20 5.3
Anti-Ro antibody (U) <20 6.1
Anti-RNP antibody (U) <20 250.4 Positive

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Anti–scleroderma-70 antibody (U) <20 4.3
Anti-Smith antibody (U) <20 2.1
case records of the massachuset ts gener al hospital

and reticular opacities in the lung bases, with

* Reference values were obtained at other laboratories and are affected by many variables, including the patient population and the laboratory methods used. They may therefore not be
2–3 ill-defined bands
architectural distortion and limited areas show-

of IgG, without
Monoclonal band
ing honeycombing (Fig. 1C). These findings are

light chains
408
2,180
104
most consistent with pulmonary fibrosis, proba-

3.6
0.4
1.0
1.5
0.6
bly related to rheumatoid arthritis. There are also
scattered pulmonary nodules, which could be
granulomas, hyperplastic intraparenchymal lymph
nodes, or tumors. These cannot be further char-
Normal pattern
acterized in a single study.
Dr. Munshi: The important clinical features of
this case are the rapid development of diffuse
generalized lymphadenopathy, without systemic
symptoms such as fever, night sweats, or weight
loss; a history of gastroesophageal reflux disease;
active autoimmune disease treated with cortico-
steroids and methotrexate; and a history of sple-
nectomy. An important laboratory result is the
presence of a monoclonal serum immunoglobu-
lin. The differential diagnosis consists of com-
plications of this patient’s autoimmune disease
or its treatment, including infections and lym-
phoproliferative disorders, as well as conditions
that may mimic or be associated with autoim-
mune disorders. It is useful to consider the dif-
ferential diagnosis in the absence of the informa-
tion provided by serum protein electrophoresis
and immunofixation and then to narrow the list of
201.1

11.5
4.8

possible diagnoses with these results in mind.

Indolent Lymphomas
The presence of generalized lymphadenopathy
without prominent systemic symptoms, a relative-
Normal pattern

ly normal complete blood count, and the relatively


694–1618

Negative

3.5–5.0
0.2–0.3
0.5–0.9
81–463

48–271

0.6–1.1
0.5–1.5
0–15
0–15
<20

low serum lactate dehydrogenase level suggest an


indolent lymphoma. The most common of these
† GPL denotes IgG phospholipid, and MPL IgM phospholipid.

disorders is follicular lymphoma. However, the


relatively rapid growth of this patient’s lymph
nodes is atypical of follicular lymphoma, and he
is also young for this disease — the median age
at onset is in the sixth decade.
This patient has a history of gastroesopha-
geal reflux disease, and he reported a loss of
appetite associated with the onset of lymphade-
Extractable nuclear antibody (U)

Serum protein electrophoresis

nopathy. Extranodal marginal-zone lymphoma of


appropriate for all patients.
Anticardiolipin antibodies†

mucosa-associated lymphoid tissue (MALT lym-


Immunoglobulin (mg/dl)

phoma) typically affects the stomach, where it is


Serum globulins (g/dl)
IgM (MPL units)
IgG (GPL units)

associated with Helicobacter pylori infection; how-


Immunofixation

ever, H. pylori infection is typically not associated


Albumin

with symptoms of gastrointestinal reflux disease,


Gamma
Alpha 1
Alpha 2

and the lymphomas that arise in the setting of


Beta
IgM
IgG
IgA

H. pylori infection are typically localized to the


stomach, rarely causing generalized lymphade-

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The n e w e ng l a n d j o u r na l of m e dic i n e

young for Waldenström’s macroglobulinemia,


A since the median age at onset is in the seventh
decade, and this disorder is characterized by the
presence of an IgM rather than an IgG monoclo-
nal protein.

Aggressive Lymphomas
The relatively acute presentation and rapid growth
of lymphadenopathy raise the possibility of an
aggressive lymphoma, such as diffuse large-B-cell
lymphoma or classic Hodgkin’s lymphoma. These
B
diseases are more likely than indolent lympho-
mas to occur in relatively young patients, such as
the patient under discussion. The appearance of
a central area of necrosis within some of the
lymph nodes on the CT scan would be more typ-
ical of an aggressive lymphoma than an indolent
lymphoma. Patients with an autoimmune disease
— such as this patient, who has rheumatoid ar-
thritis and systemic lupus erythematosus — may
C be at increased risk for aggressive non-Hodgkin’s
lymphomas.
In addition to the risk associated with auto-
immune disease, this patient may be in an im-
munosuppressed state because of the use of drugs
such as methotrexate or tumor necrosis factor
antagonists to treat the autoimmune disorder.
Patients with iatrogenic immunodeficiency are at
increased risk for the development of aggressive
lymphomas, including both Hodgkin’s lymphoma
Figure 1. Radiologic Images. and diffuse large-B-cell lymphomas, which are
Panel A shows multiple enlarged lymph nodes (arrows) usually associated with Epstein–Barr virus infec-
in both AUTHOR: Munshi RETAKE
ICM axillae. Panel B shows an enhancing soft-tissue
1st

nodule FIGURE:
REG F (arrow) in 1a-c of 4
the splenectomy bed, which is con-
2nd tion. Aggressive lymphomas most often present
sistent
CASE with a splenule. Panel C shows subpleural
Revised
3rd
with localized rather than generalized lymphade-
ground-glass
EMail opacities4-C
and reticular Line in the lungs
SIZE(ar- nopathy, and when the disease is generalized, the
ARTIST: mst H/T H/T
rows)
Enonwith architectural distortion, findings 16p6
Combo
that are lactate dehydrogenase level is often elevated, and
consistent with pulmonary fibrosis. systemic symptoms are typically more severe than
AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset. those in this patient, often including fevers, night
Please check carefully.
nopathy. MALT lymphoma of nongastric sites is sweats, and weight loss. This patient had received
frequently
JOB: 35817 associated with autoimmune disease,
ISSUE: 4-24-08 methotrexate but not tumor necrosis factor an-
such as Sjögren’s syndrome and Hashimoto’s tagonists, and both methotrexate and prednisone
disease; however, it is not characteristically asso- had been discontinued long before the onset of his
ciated with rheumatoid arthritis and involves symptoms; thus, an immunosuppression-related
extranodal sites, such as the salivary gland or lymphoma seems unlikely.
thyroid. Presentation with rapidly enlarging lymph-
adenopathy would be uncommon. Infections
Lymphoplasmacytic lymphoma, which is typ- Immunodeficiency due to the use of methotrexate
ically associated with Waldenström’s macroglob- and corticosteroids may predispose patients to
ulinemia, may present with generalized lymph- opportunistic infections. Tuberculosis, viral infec-
adenopathy in a patient who is otherwise tions, and fungal infections are possible in this
relatively well, and it often has a monoclonal pro- patient with generalized lymph-node enlargement
tein on serum electrophoresis. This patient is and a history of infections, including oral candi-

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case records of the massachuset ts gener al hospital

diasis. However, the absence of fever and leuko- fixation was reported to show the presence of
cytosis argues against the presence of a systemic gamma heavy chains, without corresponding light
infection. Although patients taking high doses of chains. The presence of free heavy chains in the
immunosuppressive medications such as cortico- blood, without light chains, is the defining fea-
steroids may not have fever despite severe infec- ture of heavy-chain diseases.2,3
tions, this patient had discontinued the use of An immunoglobulin molecule is composed of
prednisone. There is no serologic evidence of an two heavy chains and two light chains, which are
acute viral infection. joined by disulfide bonds (Fig. 2). The normal
heavy-chain constant region has three domains
Castleman’s Disease (CH1-CH3); of those, CH1 is responsible for bind-
Multicentric Castleman’s disease, often a result ing to the light chain. In the absence of an as-
of infection with human herpesvirus 8, can be sociated light chain, the CH1 domain binds to
manifested as generalized lymphadenopathy heat-shock protein 78 (hsp 78) and undergoes pro-
and can be associated with HIV infection; it may teasomal degradation; it is thus not secreted.4
be associated with an IgG paraprotein.1 Anemia, Normal heavy chains not associated with light
thrombocytosis, an elevated erythrocyte sedimen- chains have never been detected in serum. In
tation rate, hypoalbuminemia, and polyclonal heavy-chain diseases, noncontiguous deletions
hypergammaglobulin­emia are commonly seen; in the switch–CH1 region prevent binding to the
although this patient’s erythrocyte sedimentation hsp 78 protein and degradation in the absence of
rate is slightly elevated, none of the other find- a light chain (Fig. 2).2
ings apply. Heavy-chain diseases (Table 3) are rare variants
of B-cell lymphomas that produce one of three
Monoclonal Gammopathy classes of immunoglobulin heavy chains: alpha,
The results of serum protein electrophoresis or- mu, or gamma.5,6 Alpha heavy-chain disease, also
dered by the patient’s primary care physician known as immunoproliferative small intestinal
shortly before his evaluation by a hematologist– disease, is a form of MALT lymphoma that devel-
oncologist showed a spike in the gamma region, ops in the small intestine in young adults living
which is consistent with the presence of a mono- in conditions of poor sanitation7,8; it may respond
clonal immunoglobulin. Many conditions (Table 2) in its early stages to treatment with antibiotics,
are associated with the presence in the blood of and Campylobacter jejuni infection has been impli-
a monoclonal protein composed of intact immu- cated in its pathogenesis.9 Mu heavy-chain disease
noglobulin molecules, with both heavy and light is an extremely rare disorder with clinical features
chains. Free light chains may be seen in the blood that resemble chronic lymphocytic leukemia and
together with intact immunoglobulin molecules distinctive vacuolated lymphocytes in the bone
or, less commonly, alone, particularly in patients marrow.10 Gamma heavy-chain disease, which is
with plasma-cell myeloma. In this case, immuno- intermediate in frequency between alpha and mu

Table 2. Causes of Monoclonal Proteins in Serum.

Condition Paraprotein (Typical) Clinical Features


Multicentric Castleman’s disease IgG or IgA, lambda HIV and human herpesvirus 8 infections, gen-
eralized lymphadenopathy, splenomegaly
Monoclonal gammopathy of unknown IgG, IgA, IgM, kappa or lambda Asymptomatic
­significance
Plasma-cell myeloma IgG, IgA, free light chains (kappa or lambda) Bone lesions, decreased normal immuno-
globulins, anemia, renal failure
Chronic lymphocytic leukemia IgM, low level Lymphocytosis, anemia, lymphadenopathy
Lymphoplasmacytic lymphoma IgM, often high level Anemia, hyperviscosity, lymphadenopathy
Splenic marginal-zone lymphoma IgM, low level Splenomegaly, anemia, lymphocytosis
Heavy-chain diseases* Free abnormal alpha, mu, or gamma heavy chains

* Clinical features of heavy-chain diseases are provided in Table 3.

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The n e w e ng l a n d j o u r na l of m e dic i n e

systemic lupus erythematosus, Sjögren’s syndrome,


Variable size and myasthenia gravis.11,13 Autoimmune manifes-
Antigen-
deletion in HCD binding tations often precede the diagnosis of lymphoma,
H H site in some cases by up to several years. The clinical
NH2 Light-chain–
L binding site: NH2
L
course may be indolent, resembling monoclonal
R1
CD R 2 deleted VH gammopathy of unknown significance, or aggres-
CD R 3
CD in HCD D
JH H
sive, involving bone marrow and other tissues.
VL
My diagnosis is gamma heavy-chain disease,
CH1 CH1
s s– JL associated with rheumatoid arthritis. The diag-
CL s– s–s s
CL nostic procedure was probably a biopsy of an en­
s–s larged lymph node or the bone marrow, and I
s–s
predict it would show some variant of lympho-
Complement- plasmacytic lymphoma, with plasma cells produc­
CH2 binding site ing gamma heavy chains without light chains.
Dr. Nancy Lee Harris (Pathology): Are there any
questions for Dr. Munshi?
Dr. Ronald S. Weinger (Hematology–Oncology,
CH3 Fc-receptor–
binding site
North Shore Cancer Center): What do you think
COOH about the radiologist’s description of an accessory
COOH spleen?
Dr. Munshi: Splenic involvement is seen in most
Figure 2. Structure of the Immunoglobulin Molecule in Heavy-Chain Disease.
COLOR FIGURE
patients with gamma heavy-chain disease. If the
An immunoglobulin molecule is composed of two heavy chains (H) and two
Draft 7 4/8/08 accessory spleen has enlarged recently, it could
light chains (L), which are joined by disulfide bonds (S–S). The normal heavy-
chain constant region has three constant domains:FigCH1
Author Munshi
is responsible for be involved in the disease process.
# 2
binding to the light chain, CH2 for binding to complement,
Title and CH3 for
Immunoglobulin Structures
A Physician: Do you think the history of a large
binding to Fc receptors. In the absence of an associated
ME light chain, the CH1
Koopman spleen is related to this diagnosis?
Harris
domain binds to heat-shock protein 78 and undergoes DE proteasomal
Artist KMK
degrada- Dr. Munshi: Although it is theoretically possible
tion; thus, normal free heavy chains are not secreted. In heavy-chain diseases
AUTHOR PLEASE NOTE: that the history of a large spleen is related, the
(HCDs), noncontiguous deletions in the CH1 domainFigure prevent both
has been redrawn andbinding
type has been reset

of the heavy chain to the light chain and degradationIssueindate


Please check carefully
the proteasome, and time from splenectomy to the current diagnosis
4/24/08
free heavy chains are secreted. Variable-sized deletions also occur in the (14 years) argues against this possibility.
heavy-chain diversity region (DH), the heavy-chain joining region (JH), and Dr. Hasan Bazari (Medicine): Is there any asso-
the heavy-chain variable region (VH). CDR denotes complementarity-deter- ciation between hepatitis C virus, Epstein–Barr
mining region, CL light-chain constant region, COOH carboxyl terminal, JL light-
virus, or human herpesvirus 8 and gamma heavy-
chain joining region, NH2 amino terminal, and VL light-chain variable region.
chain disease?
Dr. Munshi: Not that I am aware of. The major-
heavy-chain diseases, is typically associated with ity of the reports of heavy-chain disease were
a systemic lymphoma. 11 before 1980, when the role of hepatitis C virus
in lymphoproliferative disorders was not under-
Gamma Heavy-Chain Disease stood and human herpesvirus 8 had not yet been
In this patient, the presence of gamma heavy described; in reports since that time, I am not
chains without light chains strongly suggests the aware of the results of testing for these viruses.
diagnosis of gamma heavy-chain disease. Since Dr. Harris: Dr. Weinger, would you summarize
it was first reported in 1964 by Franklin12 (it is your thinking at the time you saw the patient?
also known as Franklin’s disease), only about 130 Dr. Weinger: I thought his persistent neutrope-
cases have been reported in the literature. Patients nia might be due to autoimmune neutropenia,
typically present with generalized lymphadenop- associated with his rheumatoid arthritis, despite
athy, splenomegaly, and anemia and occasionally the fact that his spleen had been removed. When
with palatal and uvular swelling. Almost one he returned with generalized lymphadenopathy,
third of patients have a history of autoimmune I believed that he probably had a lymphoma.
disease. The most common is rheumatoid arthri- When I saw him in the office, I did not have the
tis; others include autoimmune hemolytic anemia, results of the serum protein electrophoresis and
idiopathic thrombocytopenic purpura, vasculitis, immunofixation. I requested an excisional biopsy

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case records of the massachuset ts gener al hospital

Table 3. Heavy-Chain Diseases.*

Heavy-Chain Disease Associated Lymphoma Features


Alpha (immuno­ Extranodal marginal-zone B-cell Most common of the three heavy-chain diseases, com-
proliferative small lymphoma of mucosa-associat- mon in Mediterranean regions, involvement of small
intestinal disease) ed lymphoid tissue (MALT intestine, associated with intestinal parasites and
lymphoma) Campylobacter jejuni infection, may be responsive to
antibiotics early in course, may progress to diffuse
large-B-cell lymphoma
Gamma Lymphoplasmacytic lymphoma Widespread involvement of bone marrow, lymph nodes,
and spleen; associated with constitutional symptoms,
anemia, eosinophilia, and autoimmune conditions
Mu Chronic lymphocytic leukemia Rarest of the three heavy-chain diseases, systemic lym-
phoma with hepatosplenomegaly and vacuolated
bone marrow plasma cells, free urinary light chains
produced in addition to abnormal serum mu chain

* Data are from Grogan et al.5 and Fermand et al.6

of one of the enlarged lymph nodes. When the nuclei — somewhat higher than would be expect-
results of the serum protein analysis became ed for a low-grade B-cell lymphoma.
available, it was clear that the likely diagnosis A bone marrow biopsy, performed approxi-
was gamma heavy-chain disease. mately 1 month after the lymph-node biopsy, re-
vealed normal overall cellularity, with a few small
Cl inic a l Di agnosis lymphoplasmacytic aggregates (Fig. 3E). In areas
away from aggregates, small, subtle plasma-cell
Gamma heavy-chain disease. clusters could be seen. Immunohistochemical
stains showed that the plasma cells were positive
dr . nik hil c . munshi’s Di agnosis for IgG but negative for both kappa and lambda
light chains (Fig. 3F).
Gamma heavy-chain disease. Four days before the patient saw the hema-
tologist–oncologist, Dr. Weinger, serum protein
Pathol o gic a l Dis cus sion electrophoresis revealed a distinct band in the
immunoglobulin region that was anodal with
Dr. Aliyah Rahemtullah: The diagnostic procedure respect to the point of origin, which was typed
was a biopsy of an enlarged 2-cm right cervical on immunofixation as IgG without a correspond-
lymph node; the specimen was sent to this hos- ing light chain (Fig. 4A). Urinary protein electro-
pital for pathological evaluation. The lymph-node phoresis performed at the time of the bone mar-
architecture was effaced by a diffuse, polymor- row biopsy revealed a dense monoclonal band,
phous proliferation of small and medium-sized which was also typed as IgG without an associ-
lymphoid cells, some with plasmacytic differenti- ated light chain (Fig. 4B). Gamma heavy chains
ation, plasma cells, and scattered large immuno- are too large to pass into the urinary space, even
blasts (Fig. 3A). Immunohistochemical stains dem­ in patients with elevated serum levels; this find-
onstrated a mixture of CD20-positive B cells and ing suggests either impairment of renal function
CD3-positive T cells (Fig. 3B); many cells were or alteration of the heavy-chain structure, such
negative for CD20 but expressed the plasma-cell– that it is truncated and able to pass into the uri-
associated antigens CD138 and multiple myeloma nary space.
oncogene 1 (MUM1) (Fig. 3C). Staining for im- The lymphoma associated with gamma heavy-
munoglobulin heavy chains showed that the vast chain disease typically involves hematopoietic
majority of plasma cells contained cytoplasmic tissues, including bone marrow, the spleen, and
IgG, whereas in situ hybridization for immuno- lymph nodes, as in this case,5 but it may be lo-
globulin light chains showed only scattered poly- calized and involve extrahematopoietic sites, in-
typic plasma cells (Fig. 3D). Ki-67, a proliferation cluding those often involved in MALT lymphoma,
marker, was positive in approximately 40% of such as the skin, thyroid, salivary glands, and

n engl j med 358;17  www.nejm.org  april 24, 2008 1845

Downloaded from www.nejm.org on June 13, 2010 . Copyright © 2008 Massachusetts Medical Society. All rights reserved.
The n e w e ng l a n d j o u r na l of m e dic i n e

A B C

D E F

Figure 3. Biopsy Specimens of the Right Cervical Lymph Node and Bone Marrow.
The lymph-node architecture is effaced by a polymorphous lymphoid population with a diffuse pattern of growth
(Panel A, hematoxylin and eosin). Lymphocytes include small, mature-appearing forms, plasmacytoid lymphocytes
with moderately abundant cytoplasm AUTHOR: Munshi RETAKE 1st
ICM and eccentric nuclei, and medium-sized cells with dispersed chromatin and
2nd
slight nuclear irregularities (PanelREG
A, Finset). Numerous
FIGURE: 3a-f of 4plasma cells (arrows in inset) and scattered large immuno-
3rd
blasts are also present. Immunohistochemical
CASE stains show that most of the lymphoid infiltrate is composed of
Revised
CD20-positive B cells, including the immunoblasts (PanelLine
EMail B, arrow),
4-Cwith fewer
SIZECD3-positive T cells (Panel B, inset).
The numerous plasma cells scattered ARTIST: mst
throughout the lymphH/Tnode H/T
are highlighted by the plasma-cell marker CD138
Enon 33p9
(Panel C). Immunohistochemical staining for heavy chainsCombo shows that the majority of plasma cells are IgG-positive
AUTHOR, PLEASE NOTE:
(Panel D), whereas in situ hybridization for immunoglobulin kappa light chains (left inset) and lambda light chains
Figure has been redrawn and type has been reset.
(right inset) shows only scattered polytypic plasma cells. The total number of cells staining for kappa and lambda
Please check carefully.
together appeared fewer than the number of IgG-positive plasma cells. The bone marrow–biopsy specimen has an
overall cellularity of 50%, whichJOB:
is appropriate
35817
for the patient’s age, with maturing trilineage hematopoiesis (Panel
ISSUE: 4-24-08
E, Giemsa stain). A few small aggregates composed of plasma cells and lymphocytes have displaced normal hema-
topoietic elements (arrow), accounting for approximately 5% of the overall marrow cellularity. Some plasma cells are
mature, whereas others are atypical with open chromatin (Panel E, inset). Immunohistochemical staining of the
specimen from the bone marrow core biopsy shows that the atypical plasmacytic aggregates are positive for CD138
and IgG (Panel F). Only scattered IgM-positive plasma cells are present. In situ hybridization for kappa and lambda
light chains showed scattered polytypic plasma cells, but the IgG-positive plasma cells within the small aggregates
were negative for both kappa and lambda light chains.

gastrointestinal tract.6 Skeletal involvement is ally, mature plasma cells predominate, or patients
rare, and amyloid deposits are not found because may present with peripheral-blood lymphocyto-
of the absence of light-chain production; gamma sis.6,14 Unusual features, such as the presence of
heavy-chain disease, therefore, almost never cells resembling Reed–Sternberg cells, increased
mimics multiple myeloma clinically.6 eosinophils and histiocytes, and vascular prolif-
Pathological examination most commonly eration may give rise to the histologic differen-
demonstrates a mixed proliferation of lympho- tial diagnosis of Hodgkin’s lymphoma or certain
cytes, plasmacytoid lymphocytes, plasma cells, forms of T-cell lymphoma.6 Unlike alpha heavy-
and scattered immunoblasts, as were seen in this chain disease, gamma heavy-chain disease only
case.6 These findings resemble those of lympho- rarely progresses to diffuse large-B-cell lympho-
plasmacytic lymphoma; however, the infiltrate is ma.5,6,14 Because of the association of gamma
often more polymorphous, with more numerous heavy-chain disease with rheumatoid arthri-
immunoblasts and medium-sized cells. Occasion- tis,6,14,15 the differential diagnosis may include

1846 n engl j med 358;17  www.nejm.org  april 24, 2008

Downloaded from www.nejm.org on June 13, 2010 . Copyright © 2008 Massachusetts Medical Society. All rights reserved.
case records of the massachuset ts gener al hospital

the more common entity of rheumatoid-arthritis– A Serum


associated reactive lymphadenopathy, which may +
be generalized or located near the site of an in-
flamed joint and is characterized by follicular
hyperplasia.16
After the diagnosis was made, we reviewed the
prior splenectomy specimen, which revealed reac-
tive follicular hyperplasia, without morphologic
evidence of lymphoma; tissue was no longer O
available to assess immunoglobulin heavy-chain
and light-chain expression. A specimen from a
bone marrow biopsy at that time showed normal −
SPE IgG IgA IgM κ λ
hematopoiesis, without morphologic evidence of
lymphoma. The biopsy specimen of the skin ob- B Urine
tained 19 months earlier revealed dermatitis with +
features that were compatible with subacute cu-
taneous lupus erythematosus; however, the find-
ings were morphologically indistinguishable from
a drug hypersensitivity reaction.
In summary, several findings confirmed the
diagnosis of gamma heavy-chain disease. These
were the presence of free gamma heavy chains O
without corresponding light chains in serum and
urine and the involvement of lymph nodes and
bone marrow by a B-cell lymphoma with plasma- −
cytic differentiation, expressing gamma heavy UPE IgG IgA IgM κ λ

chains without light chains.


Figure 4. Results of Serum Protein Electrophoresis and Immunofixation
Dr. Harris: Dr. Munshi, what treatment would Performed 4 Days before Evaluation and Urinary Protein Electrophoresis
you recommend? and Immunofixation Performed
AUTHOR: at the Time of the Bone
Munshi Marrow
RETAKE 1st Biopsy.
ICM
Dr. Munshi: In some patients, the disease is Protein electrophoresis
REG F relies
FIGURE: 4 on
of the
4 separation of proteins 2nd
according to
3rd
indolent, and the patient can be followed with- properties of charge
CASE and size at pH 8.6 when a sampleRevised is applied at the ori-
out specific intervention. In a patient such as this gin (o) of an agarose
EMail gel. Most proteins are negatively
Line 4-C charged
SIZE at this pH
and migrate toward ARTIST:
the ts charged
positively H/T electrode
H/T (anode). The band in
one, with overt lymphoma, therapeutic interven- Enon
Combo
22p3
the most anodal position is albumin. Immunoglobulins are largely uncharged
tion may include cyclophosphamide, vincristine, at this pH and either remainAUTHOR,
around PLEASE NOTE:
the point of origin or migrate toward
and prednisone, with or without doxorubicin, Figure electrode
the negatively charged has been redrawn and type
(cathode) haswith
along beenthe
reset.
bulk flow of the
Please check carefully.
which have been used with some success.10,13 If buffer. In a patient who does not have a serum monoclonal component
the lymphoma cells express CD20, the anti-CD20 (M component), the expected polyclonal immunoglobulin pattern would
JOB: 35817 ISSUE: 4-24-08
be a faint, even smear across this region of the gel, without distinct bands.
monoclonal antibody, rituximab, may be useful;
However, in this patient, a distinct band was identified by serum protein
in one case, it appeared to be effective.14 The electrophoresis (SPE) in the immunoglobulin region anodal to the point of
prognosis is highly variable; in one review, sur- origin (Panel A, arrow). M components are characterized further by immuno-
vival ranged from 1 month to more than 21 years, fixation to identify the heavy and light chains that make up the paraprotein.
with a median of 7.4 years.14 In this patient, the M component typed as IgG (denoted by the band seen
in the IgG lane in Panel A), but without a corresponding light chain (only
Dr. Harris: Dr. Weinger, would you tell us how
faint polyclonal patterns can be seen in the kappa and lambda lanes in
you treated the patient? Panel A). Urinary protein electrophoresis (UPE) performed approximately
Dr. Weinger: I treated him with four weekly 1 month later revealed similar results (Panel B), with a broad monoclonal
doses of rituximab; within 2 weeks, the lymph- band corresponding to IgG, without a corresponding light chain. Calculated
adenopathy had disappeared and he felt better; total urinary IgG was approximately 225 mg per deciliter.
in retrospect, he felt he had been much sicker

n engl j med 358;17  www.nejm.org  april 24, 2008 1847

Downloaded from www.nejm.org on June 13, 2010 . Copyright © 2008 Massachusetts Medical Society. All rights reserved.
case records of the massachuset ts gener al hospital

than we appreciated at the time of his presenta- body, which is the hallmark of rheumatoid arthri-
tion. I gave him four additional doses of ritux- tis. If that test is negative, he could actually have
imab, ending 1 year after the diagnosis. Ten a form of vasculitic rheumatoid-like arthritis.
months after the last dose of rituximab, both Dr. Weinger: The test for anticyclic citrullinated
the lymphoma and the rheumatoid arthritis were peptide IgG antibody was positive (at 34 U per
in clinical remission. Repeated serum protein liter; normal range, 0 to 19) 6 months after his
electrophoresis showed a very faint band of free last dose of rituximab.
gamma heavy chains. Testing for antibodies to
hepatitis C virus and human herpesvirus 8 was A nat omic a l Di agnosis
negative.
Dr. Mandakolathur R. Murali (Medicine, Allergy): Gamma heavy-chain disease and rheumatoid
The rheumatoid factor in this patient could be a arthritis.
polyclonal IgM antibody directed at the abnormal
Dr. Munshi reports receiving lecture fees from Celgene, Millen-
monoclonal heavy chain. It would be interesting nium, and Novartis. No other potential conflict of interest relevant
to look for anticyclic citrullinated peptide anti- to this article was reported.

References
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Muller-Hermelink HK, Harris NL. Plasma ease associated with Campylobacter jejuni. disease and rheumatoid arthritis. Semin
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Stein H, Vardiman JW, eds. Tumours of 10. Wahner-Roedler DL, Kyle RA. Mu-heavy 16. Ferry JA, Harris NL. Atlas of lymphoid
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Press, 2001:154-6. 11. Fermand JP, Brouet JC. Heavy-chain

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