A 65-year-old man received a diagnosis of idiopathic thrombocytopenic purpura (ITP) 2 years ago based on an isolated thrombocytopenia (55 3 10 3 /mL); however, bone marrow showed only increased megakaryocytes, including naked ones (panel A), and cytogenetic studies were unremarkable. The patient failed improvement with steroids, intravenous immunoglobulin, and Rituxan therapy. Also, romiplostim therapy was administered weekly for 4 weeks without improvement. Repeat bone marrow during romiplostim treatment showed hypercellular marrow with 60% to 70% cellularity with increased megakaryocytes and 3/4 reticulin fibrosis (panel B). Repeat marrow was done after the patient was off romiplostim for 6 weeks. The marrow showed progression of the process to a picture of myelodysplastic/myeloproliferative neoplasms (MDS/MPN) with cellularity of 90% with dysplastic megakaryocytes, granulocytosis/ myeloid hyperplasia, and 4/4 reticulin fibrosis (panel C). The blood shows leukoerythroblastosis, Pelgeroid polymorphonuclear neutrophils, and blasts (5%) (panel D).We are submitting a case of MDS/MPN, most likely misdiagnosed as ITP, that progressed rapidly after treatment with romiplostim.
Composite lymphoma (CL) refers to the presence of two or more distinct types of lymphomas in a single organ or tissue. CL is an infrequent finding and may be due to the existence of two genetically related neoplasms, i.e. transformation of a single lymphoma into another lymphoma, or be due to the presence of two clonally unrelated lymphomas. CL composed of more than two lymphomas is even rare. Herein we describe a case of diffuse large B-cell lymphoma (DLBCL) arising in a CL of follicular lymphoma (FL) and small lymphocytic lymphoma (SLL) in an inguinal lymph node of an 85 year old woman. The three lymphomas were morphologically and immunophenotypically distinct while flow cytometry detected two monoclonal B-cell populations. Karyotyping and Polymerase Chain Reaction (PCR) for B-cell clonality each detected a single monoclonal B-cell population. The morphology findings may suggest DLBCL being transformed from FL while Richter transformation from SLL appears to be less likely in our case. Due to the single clone by chromosome study and PCR study, the precise relationships of the three lymphomas are unknown.
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