J Rheum Dis.  2016 Aug;23(4):256-260. 10.4078/jrd.2016.23.4.256.

A Case of Primary Bone Marrow Diffuse Large B-cell Lymphoma Presenting with Polyarthritis

• Kim IY
• Kim D
• Park BB
• Lee WS
• Choi JY
• Sung YK

• KMID: 2352469
• DOI: http://doi.org/10.4078/jrd.2016.23.4.256

Abstract

Polyarthritis is a common manifestation of rheumatologic disorders; however, paraneoplastic arthropathies also arise as polyarthritis or polymyalgia, particularly in patients with myelomas, lymphomas, acute leukemia, and solid tumors. Because paraneoplastic syndromes, in some instances, might be manifested before a cancer diagnosis, they are difficult to diagnose and are often misdiagnosed. We experienced a 63-year-old female patient who had nonspecific arthritis on both hands and feet accompanied by fever. She had been diagnosed as rheumatoid arthritis and treated with prednisolone and disease modifying anti-rheumatic drugs (DMARDs) including methotrexate and anti-tumor necrosis factor agents. Her arthritis did not respond with anti-rheumatic treatment and diffuse large B-cell lymphoma was diagnosed by bone marrow biopsy. After 6 cycles of chemotherapy, her arthritis was improved as well as underlying lymphoma.

Keyword

Paraneoplastic syndromes; Diffuse large-cell lymphoma; Rheumatoid arthritis

MeSH Terms

Antirheumatic Agents
Arthritis*
Arthritis, Rheumatoid
B-Lymphocytes*
Biopsy
Bone Marrow*
Diagnosis
Drug Therapy
Female
Fever
Foot
Hand
Humans
Leukemia
Lymphoma
Lymphoma, B-Cell*
Lymphoma, Large B-Cell, Diffuse
Methotrexate
Middle Aged
Necrosis
Paraneoplastic Syndromes
Prednisolone
Antirheumatic Agents
Methotrexate
Prednisolone

Figure

• 

  Figure 1. Photographs of right hand showing polyarthritis at first visit (A) and improved arthritis after 6 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy (B).

• 

  Figure 2. T1-weighted magnetic resonance imaging of right hand at first visit (A) and after 6 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy (B). Tenosynovitis of proximal interphalanges joints (white arrows) and bone erosions at carpal bones (black arrows) and metacarpophalanges joints (A) had been resolved after 6 cycles of R-CHOP chemotherapy (B).

• 

  Figure 3. Whole body bone scintigraphy at first visit. Both wrists, proximal interphalanges, distal interphalanges, and meta-carpophalanges joints on hands showed increased symmetric uptake and tarsometatarsal joints and metatarsophalangeal joins were also showed increased uptake.

• 

  Figure 4. Bone marrow biopsy showed multiple lymphocytes concentrated with the various features. Lymphoid cells are oval shape and high nucleus-cytoplasm ratio (H&E, ×400; white arrow).

Reference

1. Klinkhoff A. Rheumatology: 5. Diagnosis and management of inflammatory polyarthritis. CMAJ. 2000; 162:1833–8.

2. van der Linden MP, Knevel R, Huizinga TW, van der Helm-van Mil AH. Classification of rheumatoid arthritis: comparison of the. 1987; American College of Rheumatology criteria and the 2010 American College of Rheumatology/ European League Against Rheumatism criteria. Arthritis Rheum. 2011; 63:37–42.

3. Fam AG. Paraneoplastic rheumatic syndromes. Baillieres Best Pract Res Clin Rheumatol. 2000; 14:515–33.

4. Kim SW, Chung MS, Baek GH, Jeon SH, Kwak SH, Gong HS. Palmar fasciitis and polyarthritis syndrome associated with ovarian carcinoma: a case report. J Korean Soc Surg Hand. 2009; 14:33–5.

5. Kim YI, Choi SG, Lee HJ, Lee KE, Lee SJ, Seo SR, et al. A case of paraneoplastic syndrome associated with pancreatic cancer presenting as rheumatoid arthritis. J Rheum Dis. 2011; 18:32–5.

6. Lee SI, Kim WK, Jun JS, Baik KR, Yang SH, Bang YJ, et al. A case of carcinomatous olyarthritis. J Korean Cancer Assoc. 1993; 25:307–14.

7. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/ European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010; 62:2569–81.

8. Bahat G, Kamali S, Saka B, Erten N, Karan MA, Tascioglu C. Paraneoplastic arthritis may mimic rheumatoid arthritis with symmetrical and upper extremity predilecting presentation. J Clin Rheumatol. 2009; 15:319–20.

9. Starkebaum G. Rheumatoid arthritis and lymphoma: risky business for B cells. J Rheumatol. 2007; 34:243–6.

10. Wolfe F, Michaud K. Lymphoma in rheumatoid arthritis: the effect of methotrexate and anti-tumor necrosis factor therapy in 18,572 patients. Arthritis Rheum. 2004; 50:1740–51.

11. Nishiya K, Tanaka Y. Coexistence of non-Hodgkin's lymphoma in the leukemic phase and polyarthritis simulating rheumatoid arthritis. Intern Med. 1997; 36:227–31.