Coincident intra-abdominal presentation of lymphoma and tuberculosis after long-term iatrogenic immunosuppression

Priyanka Thakur

Coincident intra-abdominal presentation of lymphoma and tuberculosis after long-term iatrogenic immunosuppression

Case Reports, 2012

BMJ Case Reports 2012; doi:10.1136/bcr.12.2011.5395 1 of 2 DESCRIPTION A gentleman aged 49 years with a prior history of long- term immunosuppressive therapy (for moderate to severe Crohn’s disease) presented to the emergency department with features of acute intestinal obstruction. In the preced- ing two decades, he had received various regimens con- taining a variety of immunosuppressive agents including prednisolone, cyclosporine and inﬂiximab. On surgical exploration, there was free ﬂuid in the abdomen, along with multiple nodular deposits over the gut loops and the mesentery (ﬁgure 1). One segment of the gut had an obstruction due to adhesions and resection-anastomo- sis was performed. The peritoneal ﬂuid had an elevated adenosine deaminase level of 63 IU/l (normal value <39 IU/l). 1 The presence of Mycobacterium tuberculosis was con- ﬁrmed by a PCR assay (Mycosure PCR- a test speciﬁc for M tuberculosis species). Pathological assessment however revealed non-Hodgkins lymphoma (NHL) which on char- acterisation was a B cell lymphoblastic lymphoma. Though the patient tolerated the surgery, the patient’s poor general condition (Karnofsky’s Performance Status score of 30%) precluded the use of any chemotherapy. He was transi- tioned to supportive care in a hospice. The patient was diagnosed to have two concurrent diseases- tuberculosis (TB) co-existing with NHL. Both of TB and NHL can be attributed to long-term immunosuppression 2 3 which was employed as part of management of Crohn’s disease. Immunosuppression (an integral part of current manage- ment in various clinical situations such as in auto-immune disorders and post-transplant patients) predisposes to infections and malignancies, and hence, an active vigilance against these must never be omitted in practise. Images in... Coincident intra-abdominal presentation of lymphoma and tuberculosis after long-term iatrogenic immunosuppression Balwant S Negi, 1 Priyanka Thakur, 2 Muninder K Negi, 3 Swaroop Revannasiddaiah 2 1 Surgery Department, Indira Gandhi Medical College, Shimla, India; 2 Radiation Therapy and Oncology Department, Regional Cancer Centre, Shimla, India; 3 Radiotherapy Department, Dr Rajendra Prasad Government Medical College, Tanda, Himachal Pradesh, India Correspondence to Dr Swaroop Revannasiddaiah, swarooptheone@gmail.com Figure 1 Intraoperative photograph depicting multiple granular deposits over the gut loops. on 13 June 2020 by guest. Protected by copyright. http://casereports.bmj.com/ BMJ Case Reports: first published as 10.1136/bcr.12.2011.5395 on 21 February 2012. Downloaded from

BMJ Case Reports 2012; doi:10.1136/bcr.12.2011.5395 2 of 2 Competing interests None. Patient consent Obtained. REFERENCES 1. Riquelme A, Calvo M, Salech F, et al. Value of adenosine deaminase (ADA) in ascitic ﬂuid for the diagnosis of tuberculous peritonitis: a meta-analysis. J Clin Gastroenterol 2006; 40:705–10. 2. Stanbury RM, Graham EM. Systemic corticosteroid therapy–side effects and their management. Br J Ophthalmol 1998; 82:704–8. 3. Watorek E, Boratynska M, Smolska D, et al. Malignancy after renal transplantation in the new era of immunosuppression. Ann Transplant 2011; 16:14–8. This pdf has been created automatically from the ﬁnal edited text and images. Copyright 2012 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Please cite this article as follows (you will need to access the article online to obtain the date of publication). Negi BS, Thakur P, Negi MK, Revannasiddaiah S. Coincident intra-abdominal presentation of lymphoma and tuberculosis after long-term iatrogenic immunosuppression. BMJ Case Reports 2012;10.1136/bcr.12.2011.5395, Published XXX Become a Fellow of BMJ Case Reports today and you can: Submit as many cases as you like ▶ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▶ Access all the published articles ▶ Re-use any of the published material for personal use and teaching without further permission ▶ For information on Institutional Fellowships contact consortiasales@bmjgroup.com Visit casereports.bmj.com for more articles like this and to become a Fellow Keep up to date with all published cases by signing up for an alert (all we need is your email address) http://casereports.bmj.com/cgi/alerts/etoc on 13 June 2020 by guest. Protected by copyright. http://casereports.bmj.com/ BMJ Case Reports: first published as 10.1136/bcr.12.2011.5395 on 21 February 2012. Downloaded from

Coincident intra-abdominal presentation of lymphoma and tuberculosis after long-term iatrogenic immunosuppression Balwant S Negi,1 Priyanka Thakur,2 Muninder K Negi,3 Swaroop Revannasiddaiah2 1Surgery Department, Indira Gandhi Medical College, Shimla, India; Therapy and Oncology Department, Regional Cancer Centre, Shimla, India; 3Radiotherapy Department, Dr Rajendra Prasad Government Medical College, Tanda, Himachal Pradesh, India 2Radiation Correspondence to Dr Swaroop Revannasiddaiah, swarooptheone@gmail.com DESCRIPTION A gentleman aged 49 years with a prior history of longterm immunosuppressive therapy (for moderate to severe Crohn’s disease) presented to the emergency department with features of acute intestinal obstruction. In the preceding two decades, he had received various regimens containing a variety of immunosuppressive agents including prednisolone, cyclosporine and inﬂiximab. On surgical exploration, there was free ﬂuid in the abdomen, along with multiple nodular deposits over the gut loops and the mesentery (ﬁgure 1). One segment of the gut had an obstruction due to adhesions and resection-anastomosis was performed. The peritoneal ﬂuid had an elevated adenosine deaminase level of 63 IU/l (normal value <39 IU/l).1 The presence of Mycobacterium tuberculosis was conﬁrmed by a PCR assay (Mycosure PCR- a test speciﬁc for Figure 1 M tuberculosis species). Pathological assessment however revealed non-Hodgkins lymphoma (NHL) which on characterisation was a B cell lymphoblastic lymphoma. Though the patient tolerated the surgery, the patient’s poor general condition (Karnofsky’s Performance Status score of 30%) precluded the use of any chemotherapy. He was transitioned to supportive care in a hospice. The patient was diagnosed to have two concurrent diseases- tuberculosis (TB) co-existing with NHL. Both of TB and NHL can be attributed to long-term immunosuppression 2 3 which was employed as part of management of Crohn’s disease. Immunosuppression (an integral part of current management in various clinical situations such as in auto-immune disorders and post-transplant patients) predisposes to infections and malignancies, and hence, an active vigilance against these must never be omitted in practise. Intraoperative photograph depicting multiple granular deposits over the gut loops. BMJ Case Reports 2012; doi:10.1136/bcr.12.2011.5395 1 of 2 BMJ Case Reports: first published as 10.1136/bcr.12.2011.5395 on 21 February 2012. Downloaded from http://casereports.bmj.com/ on 13 June 2020 by guest. Protected by copyright. Images in... REFERENCES 2. Stanbury RM, Graham EM. Systemic corticosteroid therapy–side effects and their management. Br J Ophthalmol 1998;82:704–8. 3. Watorek E, Boratynska M, Smolska D, et al. Malignancy after renal transplantation in the new era of immunosuppression. Ann Transplant 2011;16:14–8. 1. Riquelme A, Calvo M, Salech F, et al. Value of adenosine deaminase (ADA) in ascitic fluid for the diagnosis of tuberculous peritonitis: a meta-analysis. J Clin Gastroenterol 2006;40:705–10. This pdf has been created automatically from the final edited text and images. Copyright 2012 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Please cite this article as follows (you will need to access the article online to obtain the date of publication). Negi BS, Thakur P, Negi MK, Revannasiddaiah S. Coincident intra-abdominal presentation of lymphoma and tuberculosis after long-term iatrogenic immunosuppression. BMJ Case Reports 2012;10.1136/bcr.12.2011.5395, Published XXX Become a Fellow of BMJ Case Reports today and you can: Submit as many cases as you like Enjoy fast sympathetic peer review and rapid publication of accepted articles Access all the published articles Re-use any of the published material for personal use and teaching without further permission ▶ ▶ ▶ ▶ For information on Institutional Fellowships contact consortiasales@bmjgroup.com Visit casereports.bmj.com for more articles like this and to become a Fellow Keep up to date with all published cases by signing up for an alert (all we need is your email address) http://casereports.bmj.com/cgi/alerts/etoc 2 of 2 BMJ Case Reports 2012; doi:10.1136/bcr.12.2011.5395 BMJ Case Reports: first published as 10.1136/bcr.12.2011.5395 on 21 February 2012. Downloaded from http://casereports.bmj.com/ on 13 June 2020 by guest. Protected by copyright. Competing interests None. Patient consent Obtained.

The Slovak preaching writings of the 19th century. The bibliographic overview of publishing authors and their self-published and magazine-published sermons. The publication provides an overview of 19th century sermons that were published in the Slovak language. All known sermon authors have been identified. Sermons were published by Catholics and Evangelicals. The sermons were published as occasional publications, as collections of sermons, or in magazines. A significant landmark in the periodization is the year 1848. The events of the revolutionary year affected society, which was reflected in the contents of the sermons. An important event was the founding of the oldest Catholic homiletic periodical. In the first half of the century, several variants of the Slovak language alternated, after the revolution this problem was solved, the Catholics used the written language, the Evangelicals remained faithful to the biblical Czech. Preaching in the 19th century underwent a significant positive change. At the beginning of the century, it received only marginal attention in theological education. The Slovak environment felt the need for sermons in their own language. This need was solved by priests who founded homiletic magazines. They did not come out at the same time, but continuously followed each other. This tradition was born in 1848 and continues continuously to this day. Four Catholic periodicals were published: Treasures of preaching (1848 – 1869), Slovenský "Sion" (The Slovak Sion, 1869 – 1873), Kazatel (The Preacher, 1874 – 1880), Kazatelňa (The Pulpit, 1881 – 1908). Evangelicals in Lower Hungary published the magazine Slovo života (The Word of Life, 1881-1882), which was officially banned because it openly criticized Magyarization. The Catholics were more prudent, they avoided open confrontation, but when they received positive stimuli from the papal encyclicals, they used them in favour of the Slovaks. The publication of sermons in print had several meanings and significance. Occasional small or several-page prints were intended to preserve the memory and identity of the church community in which the published sermon was delivered. The preaching itself was enriched by independently published books of sermons. And the development of preaching as a professional field within church or spiritual life was only brought about by homiletic magazines. Professional periodicals were systematically published by Catholics from 1848 throughout the second half of the 19th century. Many sermons remained only in manuscripts. Homiletic writings as a whole form a significant, even extensive area of Slovak literature. Its importance lies not only in the quantity, but especially in the extent to which it was used. It captured the entire Slovak language area, which today is much smaller than in the 19th century. Sermons shaped the Slovak soul and were one of the few spiritual and cultural opportunities for education and spiritual enjoyment, because the majority of Slovaks did not have economic or other opportunities to come into contact with other, for example, secular culture.

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Coincident intra-abdominal presentation of lymphoma and tuberculosis after long-term iatrogenic immunosuppression