Cardiovascular Journal of Africa: Vol 26 No 4 (July/August 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 4, July/August 2015 AFRICA e9
Case Report
Exudative pericarditis in the evolution of a diffuse large
B-cell lymphoma
Cristina Bagacean, Adrian Tempescul, Jean-Christophe Ianotto, Veronique Marion, Dana Pop,
Mihnea Zdrenghea
Abstract
Cardiac involvement in non-Hodgkin’s lymphoma is a rare
occurrence with a dismal prognosis, which may evolve with
different clinical presentations, the most frequent being heart
failure. Diagnosis of cardiac involvement is generally made
by cardiac ultrasound. We report a case of lymphomatous
pericarditis in the evolution of a non-Hodgkin’s lymphoma,
diagnosed by PET-CT scan, and occurring concomitantly
with complete isotopic remission of enlarged mediastinal
lymph nodes following chemotherapy.
Keywords: lymphomatous pericarditis, DLBCL, cardiac involve-
ment
Submitted 30/12/13, accepted 4/2/15
Cardiovasc J Afr 2015; 26: e9–e11
DOI: 10.5830/CVJA-2015-024
Case report
We report on the case of a 51-year-old man diagnosed with a
CD20-positive diffuse, large B-cell lymphoma (DLBCL), Ann
Arbor stage IV (bone marrow), bulky (largest retroperitoneal
adenopathy of 18 cm), with an international prognostic index of
4. Cytogenetic analysis showed t(14,18) and deletion of the p53
gene. The patient was HIV negative.
At presentation, the patient had peritoneal effusion, whose
cytological examination failed to prove the presence of lymphoma
cells. Chemotherapy was started with one cycle of rituximab(R)-
COP (cyclophosphamide, vincrsitin and prednisolone), followed
by four cycles of R-VACP (rituximab plus vincristin, doxorubicin,
cyclophosphamide and prednisolone), according to GOELAMS
protocol, leading to complete remission, demonstrated by
18-F-FDG-PET scan.
The patient subsequently underwent autologous stem cell
transplantation conditioned by BEAM 140 (BCNU, cytarabine,
etoposide and melphalan); the number of re-infused CD34 +
cells was 3 × 106 cells/kg. Six months post autograft, he
presented with weakness and malaise. The CT scan showed
enlarged, compressive mediastinal lymphadenopathy. Rescue
chemotherapy was initiated with two cycles of R-ESHAP
(rituximab plus etoposide, cytarabine, methylprednisolone and
cisplatin), with only minimal response.
Because of his young age and good performance index,
continuation of the rescue treatment was decided, with two
courses of IVA75 (ifosfamide, etoposide and doxorubicin),
leading to partial remission. Since the total anthracycline dose
received to that date (490 mg/m2, close to the conventional
maximal dose of 550 mg/m2) was concerning for cardiotoxicity,
treatment was continuedwith two cycles of liposomal doxorubicin
(anthracycline preparation with far lesser cardiac toxicity) and
cyclophosphamide. The patient developed dyspnoea and lower
leg oedema.18 F-FDG PET scan evaluation showed complete
remission of the enlarged mediastinal lymph nodes, but also a
large pericardial effusion (Fig. 1).
The patient was admitted to the intensive care unit.
Two-dimensional echocardiography confirmed the presence
of a massive, 4-cm-thick pericardial effusion. Pericardial tap
drained 1 000 ml of liquid. Cytological analysis demonstrated
massive infiltrate with large CD19 + and CD5– lymphoma cells.
On fluorescence in situ hybridisation analysis, these cells showed
identical cytogenetic abnormalities to the original diagnosis. The
presence and development of lymphomatous pericardial effusion
was discordant with complete remission of the mediastinal
lymph nodes observed on the PET scan.
A cycle of R-DA-EPOCH (dose-adjusted etoposide,
doxorubicin, vincristine, cyclophosphamide and prednisone,
plus rituximab) chemotherapy was administered. This was
followed by febrile neutropenia, and death due to septic shock
13 months after the initial diagnosis.
Iuliu Hatieganu University of Medicine and Pharmacy,
Cluj-Napoca, Romania
Cristina Bagacean, MD
Dana Pop, MD
Mihnea Zdrenghea, MD,
Department of Clinical Hematology, Institute of Cancerology
and Hematology, Teaching Hospital Brest, France
Adrian Tempescul, MD
Jean-Christophe Ianotto, MD
Laboratory of Hematology, Teaching Hospital Brest, France
Veronique Marion, MD
Cardiology Department, Rehabilitation Hospital,
Cluj-Napoca, Romania
Dana Pop, MD
Department of Hematology, Ion Chiricuta Oncology
Institute, Cluj-Napoca, Romania
Mihnea Zdrenghea, MD