%0 Journal Article
%T Mycobacterium haemophilum as the Initial Presentation of a B-Cell Lymphoma in a Liver Transplant Patient
%A T. Doherty
%A M. Lynn
%A A. Cavazza
%A E. Sames
%A R. Hughes
%J Case Reports in Rheumatology
%D 2014
%I Hindawi Publishing Corporation
%R 10.1155/2014/742978
%X A 66-year-old woman presented with pustular lesions of her face, trunk, and limbs and an acute arthritis of the knees and elbows. She had a complex medical background and had been on immunosuppressants for three years after a liver transplant. Tissue samples from her skin lesions and synovial fluid showed acid-fast bacilli. Mycobacterium haemophilum, an atypical mycobacteria, was later grown on culture. During her treatment with combination antibiotic therapy, she developed a pronounced generalised lymphadenopathy. Histology showed features of a diffuse B-cell lymphoma, a posttransplant lymphoproliferative disorder (PTLD). 1. Presentation In October 2012 a 66-year-old, Filipino, retired psychiatric nurse attended the rheumatology department in a wheelchair. She gave a 3-week history of painful and swollen knees, ankles, and elbows. Walking had become difficult. Systemically she was unwell and described weight loss (five kilograms over a month), malaise, and anorexia. Widespread tender and raised pustular skin lesions (Figures 1 and 2) were noted over her face, arms, chest, and legs. She reported that these were itchy and painful and had failed to improve with a two-week course of oral flucloxacillin (500£¿mg QDS). Further examination revealed that she was clinically anaemic and confirmed a large joint polyarthritis with bilateral knee effusions. Other systems examination was unremarkable. Figure 1 Figure 2 2. Past Medical History and Medications Her significant medical history included a liver transplant, in 2009, for a primary malignant neoplasm (hepatocellular carcinoma). Her other past medical history included idiopathic thrombocytopenic purpura, type 2 diabetes (diet controlled), chronic kidney disease (stage 3), vitamin B12 deficiency, a hysterectomy (for menorrhagia), and secondary osteoporosis due to steroids. As part of her antirejection regime she had been taking mycophenolate mofetil (2 grams daily) and low dose prednisolone (5 milligrams daily). She also took alendronic acid (70£¿mg weekly) and calcium carbonate/cholecalciferol (1.5£¿g/400£¿IU daily). For her recent joint pains she had been using paracetamol and codeine. 3. Investigations Initial blood tests showed a Hb of 7.0£¿g/dL (hypochromic and microcytic), CRP 168£¿mg/L, WCC 9.6 109/L, neutrophils 9.0 109/L, urea 10£¿mmol/L, and creatinine 122£¿¦Ìmol/L. She was admitted to hospital and transfused with three units of blood. Investigations included an upper gastrointestinal endoscopy which revealed multiple shallow ulcers and positive Helicobacter pylori urease test. Her left knee aspirate showed
%U http://www.hindawi.com/journals/crirh/2014/742978/