br Case report A year old man with
Case report A 67-year-old man with a past history of hepatitis B carrier presented with body weight loss of 10 kg, general weakness and abdominal fullness for three months and was admitted for the impression of decompensated liver cirrhosis. Physical examination of the patient revealed a diffuse palpable abdominal mass without clear margin and anasarca. A complete blood count showed elevated white cell counts of 13.4 × 109/L with increased lymphocytes differential count of 27.8%, a hemoglobin concentration of 95 g/L and platelet counts of 101 × 109/L. Results of serum chemistry also revealed hypoalbuminemia of 2.2 g/dL, BUN of 28.0 mg/dL, and creatinine of 2.00 mg/dL, and elevated lactate dehydrogenase of 732 IU/L. On the day 4 of admission, the films of abdominal CT showed moderate amount of ascites and a diffusely thickened greater omentum (omental cake) with no enlarged lymph nodes in the retroperitoneum (Fig. 1). The Ascites was exudative in nature, according to high serum-ascites albumin gradient of 1.65 g/dL. Because of an elevated serum CEA of 8.3 ng/mL, colonoscopy was done on day 12 of admission but did not disclose any abnormality. Because of abnormal blood Cy3-dUTP in the ascites, the hematologist was consulted. Additional laboratory tests showed panhypogammaglobulinemia (IgG 119 mg/dL, IgA < 25 mg/dL, and IgM < 25 mg/dL] and a large amount of free lambda light chain of 4180.00 mg/L with an extremely low kappa/lambda ratio of 3.0 × 10−4 in the serum. The slides of cytology were reviewed. However, a peripheral blood smear disclosed that those increased ”lymphocytes” were actually small plasmablasts (Fig. 2). The cytology study of the ascites showed plenty of plasmablasts with similar features in blood (Fig. 3), which was positive staining to CD138 but negative to CD3 and CD20 (Fig. 4). Furthermore, the patient\'s bone marrow biopsy was done on day 13 of admission and showed an increased number of plasmablasts contributing to 80% of nucleated cells (Fig. 5), and thus confirmed the diagnosis of primary plasma cell leukemia. During the period of hospitalization, the patient was lethargy, and had poor appetite. Aggressive management of leg edema was done using diuretics and albumin, and, in addition, oral opioids and intravenous antibiotics given for intermittent abdominal pain and the pressure ulcer of right ankle. In the afternoon on day 14 of admission, acute onset of shortness of breath was complained. Then declined oxygen saturation to 88% under room air were noted abruptly. Physical examination of the patient showed basal rales over bilateral lung fields. Chest plain film showed increasing bronchovascular infiltration over bilateral lung fields and bilateral cardiophrenic angle blunting as compared with the image on the admission (Fig. 6). Lab data showed slightly elevated serum creatinine, CRP, and d-dimer level. Serum cardiac enzymes and procalcitonin level were within normal range. Arterial blood gas sampling showed poor PaO2/FiO2 ratio and respiratory alkalosis. We gave empirical antibiotic, inhaled bronchodilators and diuretics with colloid fluid, but respiratory distress worsened followed by systolic blood pressure dropped to below 80 mmHg. Despite of oxygen supplement, saturation of oxygenation still dropped rapidly. Delivering of endotracheal tube intubation was suggested but his family refused due to his old age and malignancy. The patient was finally died at the night of day 14 in the hospital.
Discussion “Omental cake” is a specific term used to describe this serious peritoneal disease with a mass-like feature. Metastatic involvement is the most common etiology of omental cakes, and is usually associated with a poor prognosis. Ovarian cancer is the most common prototype malignancy to produce omental cake and colonic, pancreatic, and gastric cancers are the other common malignancies that may also result in omental cakes. However, it could occur in numerous other malignancies such as endometrial cancer, bladder cancer, melanoma, lung cancer, breast cancer, renal cell carcinoma or hematological malignancies such as lymphoma. To the best of our knowledge, omental cake has never been previously mentioned associated with the presentation of PPCL.