J Rheum Dis.  2011 Dec;18(4):315-319. 10.4078/jrd.2011.18.4.315.

A Case of Ankylosing Spondylitis with Follicular Lymphoma

• Park HJ
• Park YH
• Park KH
• Kim M
• Choe EY
• Han JW
• Hong JY
• Chang MH
• Kim SJ
• Shim JE
• Kie JH
• Lee SW
• Park YB
• Lee SK
• Lee CH

• KMID: 2223138
• DOI: http://doi.org/10.4078/jrd.2011.18.4.315

Abstract

Several autoimmune and chronic inflammatory conditions have been consistently linked with an increased risk of hematologic malignancies. Although ankylosing spondylitis (AS) is a chronic inflammatory disease, previous studies have demonstrated that it is not associated with an increase in risk of malignant lymphomas. Cases of AS accompanied by hematologic malignancies such as multiple myeloma, chronic myelogenous leukemia, and Hodgkin's disease have been reported. In Korea, AS with non-Hodgkin's lymphoma or follicular lymphoma has not been reported. We experienced a 38-year-old male who had been diagnosed with follicular lymphoma with bone metastasis, who achieved complete remission after having been treated with chemotherapy, developed new inflammatory back pain. An MRI of his hip showed an active inflammation of the left sacroiliac joint and a positive HLA-B27. The patient was diagnosed with AS and was treated with naproxen, which improved the pain in his back and buttock.

Keyword

Ankylosing spondylitis; Non-Hodgkin's lymphoma; Follicular lymphoma; Inflammatory back pain

MeSH Terms

Adult
Back Pain
Buttocks
Hematologic Neoplasms
Hip
HLA-B27 Antigen
Hodgkin Disease
Humans
Inflammation
Korea
Leukemia, Myelogenous, Chronic, BCR-ABL Positive
Lymphoma
Lymphoma, Follicular
Lymphoma, Non-Hodgkin
Male
Multiple Myeloma
Naproxen
Neoplasm Metastasis
Sacroiliac Joint
Spondylitis, Ankylosing
HLA-B27 Antigen
Naproxen

Figure

• 

  Figure 1. (A) In 2007, this PET MIP image in 2007 taken at the diagnosis of lymphoma showed multiple hypermetabolic lymphadenopathy compatible with lymphoma and bone involvement at multiple sites of vertebrae (arrow) and pelvis. (B) A Bone bone scan showed shows moderately increased uptake at L4 compatible with compression fracture.

• 

  Figure 2. Pathology of follicular lymphoma. (A) On H&E section, the enlarged follicles are arranged back to back (H&E, ×100) and on high power, follicular germinal center is replaced by centroblasts, without tin-gible body macrophages and pol-arity. The surrounding mantle zone is attenuated (B, H&E, ×200). On immunohistochemical stain, these cells were positive for CD20 (C) and Bcl-2 (D).

• 

  Figure 3. Pelvis AP X-ray shows mild sclerotic changes and erosions along the bilateral SI joints (arrow).

• 

  Figure 4. A Bone bone scan in 2011 at the diagnosis of ankylosing spondylitis shows mildly increased uptake at lower portion of the left SI joint region (arrow) and the left 1st metatarsal joint area (arrow).

• 

  Figure 5. Magnetic resonance im-aging of hip shows irregular cortical erosion with subchondral cystic, sclerotic change along the SI joint, both and prominent inflammatory arthritis of the left SI joint (arrow). (A) PD fat suppression coronal scan (B) T1-weighted fat suppression with Gadolinium enhancement coronal scan.

Reference

References

1. Ekström Smedby K, Vajdic CM, Falster M, Engels EA, Martínez-Maza O, Turner J, et al. Autoimmune disorders and risk of non-Hodgkin lymphoma subtypes: a pooled analysis within the InterLymph Consortium. Blood. 2008; 111:4029–38.

2. Askling J, Klareskog L, Blomqvist P, Fored M, Feltelius N. Risk for malignant lymphoma in ankylosing spondylitis: a nationwide Swedish case-control study. Ann Rheum Dis. 2006; 65:1184–7.

3. Smedby KE, Askling J, Mariette X, Baecklund E. Autoimmune and inflammatory disorders and risk of malignant lymphomas–an update. J Intern Med. 2008; 264:514–27.

4. Choi WH, Ji EH, Lee JH, Kim SW, Min JS, Park HW, et al. A case of ankylosing spondylitis accompanied by chronic myelogenous leukemia. J Korean Rheum Assoc. 2010; 17:417–21.

5. Moon HI, Chang HJ, Kim JE, Ko HY, Ann SH, Min CK. The association between multiple myeloma and ankylosing spondylitis: a report of two cases. Korean J Hematol. 2009; 44:182–7.

6. Park DJ, Moon SD, Byun BH, Park SH, Lee SH, Cho CS, et al. Hodgkin's disease developed in a patient with ankylosing spondylitis. Korean J Med. 1995; 48:531–5.

7. Askling J, Fored CM, Baecklund E, Brandt L, Backlin C, Ekbom A, et al. Haematopoietic malignancies in rheumatoid arthritis: lymphoma risk and characteristics after exposure to tumour necrosis factor antagonists. Ann Rheum Dis. 2005; 64:1414–20.

8. Zintzaras E, Voulgarelis M, Moutsopoulos HM. The risk of lymphoma development in autoimmune diseases: a meta-analysis. Arch Intern Med. 2005; 165:2337–44.

9. Baecklund E, Iliadou A, Askling J, Ekbom A, Backlin C, Granath F, et al. Association of chronic inflammation, not its treatment, with increased lymphoma risk in rheumatoid arthritis. Arthritis Rheum. 2006; 54:692–701.

10. Au WY, Hawkins BR, Cheng N, Lie AK, Liang R, Kwong YL. Risk of haematological malignancies in HLA-B27 carriers. Br J Haematol. 2001; 115:320–2.

11. Sant M, Allemani C, Tereanu C, De Angelis R, Capocaccia R, Visser O, et al. HAEMACARE Working Group. Incidence of hematologic malignancies in Europe by morphologic subtype: results of the HAEMACARE project. Blood. 2010; 116:3724–34.

12. Chang MH, Kim SJ, Kim K, Oh SY, Lee DH, Huh J, et al. Clinical features and treatment outcomes of adult B-and T-lymphoblastic lymphoma: results of multicentre analysis in Korea. Leuk Lymphoma. 2009; 50:1119–25.

13. Calin A. Back pain: mechanical or inflammatory? Am Fam Physician. 1979; 20:97–100.

14. van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984; 27:361–8.

15. Song IH, Heldmann F, Rudwaleit M, Listing J, Appel H, Braun J, et al. Different response to rituximab in tumor necrosis factor blocker-naive patients with active ankylosing spondylitis and in patients in whom tumor necrosis factor blockers have failed: a twenty-four-week clinical trial. Arthritis Rheum. 2010; 62:1290–7.