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  Table of Contents  
LETTER TO EDITOR
Year : 2014  |  Volume : 51  |  Issue : 3  |  Page : 385-386
 

Lymphoma of bone masquerading as osteomyelitis and causing compartment syndrome of the leg


Department of Orthopaedics, Dr. Ram Manohar Lohia Hospital, New Delhi, India

Date of Web Publication10-Dec-2014

Correspondence Address:
Dr. Pankaj Bansal
Department of Orthopaedics, Dr. Ram Manohar Lohia Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.146764

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How to cite this article:
Lal H, Bansal P, Mittal D, Khare R. Lymphoma of bone masquerading as osteomyelitis and causing compartment syndrome of the leg. Indian J Cancer 2014;51:385-6

How to cite this URL:
Lal H, Bansal P, Mittal D, Khare R. Lymphoma of bone masquerading as osteomyelitis and causing compartment syndrome of the leg. Indian J Cancer [serial online] 2014 [cited 2019 Sep 17];51:385-6. Available from: http://www.indianjcancer.com/text.asp?2014/51/3/385/146764


Sir,

Primary lymphoma of bone (PLB) is an uncommon bone tumor and accounts for less than 5% of all malignant bone tumors. [1] PLB has been reported in patients as young as two years and as old as 88 years (mean age, 42 years). [2] We report a rare case of PLB with sclerotic lesion which initially misdiagnosed and treated as chronic osteomyelitis later on led to compartment syndrome of the leg.

A 35-year-old female presented to us with complains of pain in right upper leg and gradually increasing swelling of the calf for the last four months. Patient did not have any history of trauma. On examination, temperature of skin over tibia was raised. The movements of knee, ankle, and hip joint were normal. There was no lymphadenopathy. Blood pressure, Chest radiograph, and blood investigations were normal. Radiograph of right leg showed sclerotic lesion in the upper tibia [Figure 1]. A presumptive clinical diagnosis of osteomyelitis and osteosarcoma was kept. CT scan was done which diagnosed the lesion as osteomyelitis. To confirm the diagnosis, open biopsy was done. Biopsy was also reported as chronic osteomyelitis. Patient was treated accordingly for osteomyelitis conservatively and discharged. Patient was again admitted after three months with hot and angry looking swelling of proximal calf and pitting edema over proximal tibia and whole of right leg [Figure 2] accompanied with a localized swelling in right groin. Clinical examination of groin swelling confirmed it as lymphadenopathy. Biopsy of the groin lymph node was done and reported as chronic nonspecific inflammation. Contrast-enhanced MRI study reported it again as Chronic Osteomyelitis. Patient's condition deteriorated with time, causing posterior compartment syndrome of leg. The whole leg became grossly swollen and decision of repeat open biopsy from proximal tibia and decompression of compartments of leg was taken. Unfortunately, the biopsy site got infected and patient went into septic shock; and was shifted to intensive care unit. Histopathological examination and further Immunohistochemistry of biopsy confirmed the diagnosis as Non-Hodgkin's lymphoma-B-cell type [Figure 3]. Atypical lymphoid cells are strongly positive for Leukocyte common antigen and CD20 and negative for CD3 and CD99. The operative wound got worse, she was planned for amputation, but before that she died.
Figure 1: Anteroposterior Radiograph of right leg showing sclerotic lesion of proximal tibia

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Figure 2: Clinical presentation of case showing gross swelling of right leg

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Figure 3: Microscopically (H and E staining, x200), malignant lymphoma of the bone showing diffuse polymorphous population of atypical lymphoid cells which are two to three times the size of mature lymphocytes and some cells also showing nuclear cleaving

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Patients of PLB usually presents with pain only without any systemic manifestations. [3] This can lead to misdiagnosis as in our case. PLB usually causes purely lytic lesion and rarely causes purely blastic lesion (2%). [2] Purely blastic lesion can lead to misdiagnosis as in our case. Since CT and MR imaging features are not specific in case of lymphoma of bone, to confirm the diagnosis, biopsy with immunohistochemistry staining is a must. PLB can be classified on the basis of nuclear morphology as cleaved, noncleaved, and pleomorphic types. [4] Patients with tumors composed of cells with cleaved nuclei have better prognosis. The rarity of bone lymphoma and the misleading histological and imaging features can cause considerable difficulty in diagnosing this entity.


  Acknowledgments Top


We thank Vinod Kumar Sabarwal, MS, from Department of Orthopaedic Surgery, for gathering the patient data. We also thank Harendra Kumar, MD, from Department of Pathology for help in the diagnosis.

 
  References Top

1.
UnniKK.Malignant lymphoma of bone. In: UnniKK, editor.Dahlins bone tumors. 5 th ed.Philadelphia: Lippincott-Raven; 1996. p. 237-8.  Back to cited text no. 1
    
2.
MulliganME, McRaeGA, MurpheyMD.Imaging features of primary lymphoma of bone. AJR Am J Roentgenol 1999;173:1691-7.  Back to cited text no. 2
    
3.
ParkerF, JacksonH.Primary reticulum cell sarcoma of bone. SurgGynecolObstet1939;68:45-53.  Back to cited text no. 3
    
4.
Dosoretz DE, Raymond AK, Murphy GF, Doppke KP, Schiller AL, Wang CC, et al.Primary lymphoma of bone: The relationship of morphologic diversity to clinical behavior. Cancer1982:50;1009-14.  Back to cited text no. 4
    


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