Reviewing the literature we knew that in cases of
Reviewing the literature, we knew that in cases of AA, use of IST should be cautious, as IST might accelerate occult lymphoma escaping immune surveillance and evolving as a refractory lymphoma. Second, in cases of AA and concomitant NHL, to choose cytotoxic chemotherapy or IST is an art. Depending on the intensity of immunogenic cytopenia and aggressiveness of NHL, physician might decide which aims should be treated first. In this case, splenomegaly at her first presentation is difficult to prove it lymphoma. However, lately lymphadenopathy and worsening splenomegaly confirmed lymphoma involvement. Her presentation of AA might be an immunogenic prodrome of DLBCL rather than hypersplenism related. It should be noted that splenomegaly are not features of aplastic anemia; such findings suggest an alternative diagnosis such as a clonal myeloid or lymphoid disease, although there has been a rare case report of splenomegaly associated with AA. There is also a possibility that this patient had both aplastic anemia and diffuse large B-cell lymphoma. Aplastic anemia was refractory to steroid but responsive to rituximab. Medinger et al described two cases of concomitant AA and NHL, one case of multiple myeloma and concomitant AA. All of their hematopoiesis failed recovery after short course of chemotherapy, despite all attaining complete remission. The former two received IST and allo-HSCT respectively. Both restored hematopoiesis; the last one receiving IST, having temporary recovery, but still died of aplasia and infection. According to literature, hematopoiesis seldom recovers in cases of NHL with antecedent or concomitant AA despite remission of lymphoma. Nevertheless, here we provided a case report of DLBCL with initial presentation of AA. Hematopoiesis recovered after first bupropion hydrochloride of chemotherapy, and later a successful stem cell harvest after complete remission of lymphoma.
Conflict of interest
Acknowledgements This work was partially supported from the Taipei Veterans General Hospital (V104C-182), and National Yang-Ming University.
Introduction Pancreatic cancer has been the eighth leading cause of cancer-related deaths in Taiwan in recent years. In most cases, the outcome of pancreatic cancer is poor. The clinical manifestations of pancreatic tumors are epigastralgia, jaundice, steatorrhea, body weight loss, vomiting, anorexia, and asthenia. Initial clinical presentations, such as painless jaundice and new onset diabetes, may be early signs of a pancreatic head tumor. Diagnostic tools for pancreatic cancer include transabdominal ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS). In recent years, improvements in the imaging technologies mentioned above have helped in the early detection of pancreatic cancer. The high sensitivity and specificity of EUS plays an important role when trying to identify a small pancreatic tumor. It also helps in obtaining tissue samples via fine needle aspiration.
Case report Biochemistry data revealed hyperbilirubinemia (total bilirubin level: 13 mg/dL, direct bilirubin level: 8.0 mg/dL), elevated alkaline phosphate (ALK-P: 688 IU/L) level, elevated r-glutamyl transpeptidase (r-GT: 1842 IU/L) level, and an abnormal liver function test (aspartate transaminase [AST] level: 230 IU/L, alanine transaminase [ALT] level: 395 IU/L). The patient\'s serum sample tested negative for hepatitis B and hepatitis C. Echography showed a gallbladder (GB) stone and common bile duct (CBD) dilatation. Conventional abdominal CT with and without contrast also confirmed the presence of GB stones and CBD dilatation. It did not reveal any abnormal pancreatic head lesion (Fig. 1). Endoscopic retrograde cholangiopancreatography (ERCP) was performed under the indication of obstructive jaundice. The fluoroscopy showed proximal CBD dilatation with an abrupt distal CBD stricture. One plastic stent (8.5 Fr, 9 cm) was placed in the distal CBD (Fig. 2A). A biopsy was obtained from the edematous change of the papilla with villous appearance (Fig. 2B). The final pathological result was chronic inflammation.