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May 25, 2018

Pushing Glass (May 25, 2017)

Large B-cell Lymphoma, arkana laboratories, pushing glass

The patient is a 74 year-old female who presents with a sudden rise in creatinine to 5.0. A week ago at her annual physical, her creatinine was 1.0. She presents to the hospital with dehydration and flu like symptoms. She has a history of hypertension and CLL which is followed by oncology.

What is the best diagnosis?

1. Acute interstitial nephritis

2. Chronic lymphocytic leukemia

3. Large B-Cell Lymphoma arising from chronic lymphocytic leukemia

4. Acute tubular injury

acute kidney injury, IF staining, kidney biopsy, arkanaChronic lymphocytic leukemia, large cell, kidneyCLL, renal biopsy, kidney pathology richter, renal disease, renal biopsy, Jones stain, Large B-cell Lymphoma

The best answer is (Answer 3) Large B-cell lymphoma arising from chronic lymphocytic leukemia.

The biopsy shows a very brisk interstitial infiltrate and but unremarkable glomeruli (A&B). On higher magnification, the cells are large with prominent nucleoli (C&D). Even though the patient does have a history of chronic lymphocytic leukemia, the size of the cells and the diffuse staining for CD20 (E) is in keeping with large B-cell lymphoma. Richter’s transformation refers to the development of aggressive lymphoma during the course of CLL. This is an uncommon complication which occurs in about 5% of patients with CLL. Diffuse large B-cell lymphoma occurs in the majority of these transformations. The presence of diffuse staining for CD20, a high proliferation index (MIB-1 stain not shown), and TP53 positivity (not shown) is consistent with a Richter’s transformation. Clinically, patients with Richter’s transformation usually present with rapidly enlarging lymph nodes, hepatosplenomegaly, and elevated serum lactate dehydrogenase levels. Acute interstitial nephritis could also cause a rapid increase in serum creatinine, but the cells in the infiltrate shown are neoplastic and not simply reactive. And, while acute tubular injury is present and likely a component of the increase in creatinine, but the predominant disease process is large B-cell lymphoma.