Leila Shafiq^1,, Andrew J Shychuk², Joanna M Chaffin³

Non-Hodgkin’s lymphomas (NHL) manifest in a multitude of presentations dependent on the subtype, aggressiveness, and primary location of the lymphoma. Because of varied clinical presentations, NHL can oftentimes be difficult to diagnose. However, a high index of suspicion and timely diagnosis is critical, especially in the case of aggressive NHL, in order to initiate prompt treatment for the most optimal outcomes. Here we describe the case of a 62 year-old Caucasian male who presented to a new primary care provider for further evaluation of edema, at which time he was found to have evidence of progression to anasarca along with evidence of protein-losing enteropathy. This occurred after initial workup for symptoms had been terminated prematurely by the previous provider with a move toward symptomatic management without establishing a diagnosis due diagnostic challenges of his nonspecific symptoms. The disease course had an insidious onset. By the time adenopathy became apparent and was biopsied, a diagnosis of aggressive and advanced angioimmunoblastic T-cell lymphoma and secondary Epstein-Barr virus (+) B-cell lymphoma was eventually made. This case highlights an uncommon form of aggressive NHL (angioimmunoblastic T-cell lymphoma) presenting insidiously as edema most likely secondary to protein-losing enteropathy. Lymphatic invasion can obstruct drainage leading to intestinal lymphangiectasia, ulceration, and inflammatory exudation of protein causing anasarca. Additional mechanisms postulated in the presentation of edema in NHL include an increase in Tumor Necrosis Factor Alpha and vascular endothelial growth factor. Therefore, it is important to consider the diagnosis of NHL in patients with similar manifestations when workup is otherwise inconclusive. Additionally, this case brings to light the critical role that primary care providers can play in maintaining a high index of suspicion for cancer, continuing to work up patients not responsive to initial therapy in a prompt manner to mitigate any delays in diagnosis.

NHL, anasarca, lymphoma, protein losing enteropathy, edema, primary care