A 13-year-old girl was admitted to our department with a history of severe pain of her left axilla and fever. On physical examination, a block of lymph nodes in her left axilla, diffuse papular rash, and red-violet swelling of her supraclavicular and subclavian region were noted. Imaging investigations revealed left axillar and supraclavicular lymphadenopathy and a small nodular shade in the upper lobe of her left lung. A biopsy from an axillary lymph node established the diagnosis of anaplastic large cell lymphoma (ALCL), whereas DNA of Mycobacterium tuberculosis was detected by polymerase chain reaction (PCR) in the same tissue biopsy. Patient was started on chemotherapy for ALCL and achieved remission of all initially involved fields. Nevertheless, two new nodular lesions were detected in the left lower lobe. Biopsy revealed granulomas, and PCR was positive for M. tuberculosis. Our patient received treatment with the combination of isoniazid and rifampin (12 months), pyrazinamide (the first 2 months), and maintenance chemotherapy for her ALCL for one year simultaneously. Four years later, she is disease free for both mycobacterial infection and lymphoma. We are reporting this successful management of mycobacterial infection in a patient with ALCL despite intensive chemotherapy that the patient received at the same time. 1. Introduction Children with cancer have an increased risk for life-threatening infections due to their underlying illness and intensive anticancer treatment as well [1]. Certain types of cancer, particularly Hodgkin’s disease and non-Hodgkin’s lymphoma, are associated with impaired cellular immunity which may persist even after the end of treatment while the disease is in remission [1, 2]. Chemotherapy in these diseases is an additional factor of altered cellular immunity [1]. Although the majority of infections in children with cancer are caused by bacteria, infections due to mycobacteria are also reported and may be severe and life threatening [1, 3]. In this report we describe a case of pulmonary tuberculosis (TB) in a girl with Anaplastic Large Cell Lymphoma (ALCL). 2. Case Report A 13-year-old girl was admitted to our department with a history of severe pain of her left axilla and limitation of her left arm active movements during the last 3 weeks. The parents reported no history of any other associated symptoms apart from fever of 39°C three days after the first appearance of pain. No history of decreased appetite was reported. No prior surgeries or medical problems were also mentioned. On physical examination, she was well
References
[1]
A. Y. Koh and P. A. Pizzo, “Infectious diseases in pediatric cancer,” in Oncology of Infancy and Childhood, S. H. Orkin, D. E. Fisher, A. T. Look, S. E. Lux, D. Ginsburg, and D. G. Nathan, Eds., pp. 1099–1120, Saunders Elsevier, Philadelphia, Pa, USA, 1st edition, 2009.
[2]
D. J. Slivnick, J. F. Nawrocki, and R. I. Fisher, “Immunology and cellular biology of Hodgkin's disease,” Hematology/Oncology Clinics of North America, vol. 3, no. 2, pp. 205–220, 1989.
[3]
C. Viscoli, E. Castagnola, and D. Rogers, “Infections in the compromised child,” Bailliere's Clinical Haematology, vol. 4, no. 2, pp. 511–543, 1991.
[4]
E. Jacobsen, “Anaplastic large-cell lymphoma, T-/null-cell type,” Oncologist, vol. 11, no. 7, pp. 831–840, 2006.
[5]
A. Reiter and A. A. Ferrando, “Malignant Lymphomas and Lymphadenopathies,” in Oncology of Infancy and Childhood, S. H. Orkin, D. E. Fisher, A. T. Look, S. E. Lux, D. Ginsburg, and D. G. Nathan, Eds., pp. 417–505, Saunders Elsevier, Philadelphia, Pa, USA, 1st edition, 2009.
[6]
A. Fornari, R. Piva, R. Chiarle, D. Novero, and G. Inghirami, “Anaplastic large cell lymphoma: one or more entities among T-cell lymphoma?” Hematological Oncology, vol. 27, no. 4, pp. 161–170, 2009.
[7]
E. J. Lowe, R. Sposto, S. L. Perkins et al., “Intensive chemotherapy for systemic anaplastic large cell lymphoma in children and adolescents: final results of children's cancer group study 5941,” Pediatric Blood and Cancer, vol. 52, no. 3, pp. 335–339, 2009.
[8]
S. H. Swerdlow, E. Campo, N. L. Harris et al., WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, IARC Press, Lyon, France, 4th edition, 2008.
[9]
D. Benharroch, Z. Meguerian-Bedoyan, L. Lamant et al., “ALK-positive lymphoma: a single disease with a broad spectrum of morphology,” Blood, vol. 91, no. 6, pp. 2076–2084, 1998.
[10]
L. Brugières, M. C. Le Deley, H. Pacquement et al., “CD30+ anaplastic large-cell lymphoma in children: analysis of 82 patients enrolled in two consecutive studies of the French Society of Pediatric Oncology,” Blood, vol. 92, no. 10, pp. 3591–3598, 1998.
[11]
M.-C. Le Deley, A. Reiter, D. Williams et al., “Prognostic factors in childhood anaplastic large cell lymphoma: results of a large European intergroup study,” Blood, vol. 111, no. 3, pp. 1560–1566, 2008.
[12]
“Annexes 2 and 3 of Global tuberculosis control: epidemiology, strategy, financing,” WHO Report WHO/ HTM/TB/2009. 411, World Health Organization, Geneva, Switzerlands, 2009, http://www.who.int/tb/publications/global_report/.
[13]
US Department of Health and Human Services, “Reported tuberculosis in the United States,” 2004, http://wonder.cdc.gov/tb.html.
[14]
M. Kamboj and K. A. Sepkowitz, “The risk of tuberculosis in patients with cancer,” Clinical Infectious Diseases, vol. 42, no. 11, pp. 1592–1595, 2006.
[15]
C. Lancioni, A. D. LaBeaud, F. Esper, N. Abughali, and J. Auletta, “Pulmonary tuberculosis presenting as fever without source in a pediatric patient with acute lymphoblastic leukemia,” Pediatric Blood and Cancer, vol. 53, no. 7, pp. 1318–1320, 2009.
[16]
B. Khan, P. Ahmed, K. Ullah, C. A. Hussain, I. Hussain, and S. Raza, “Frequency of tuberculosis in haematological malignancies and stem cell transplant recipients,” Journal of the College of Physicians and Surgeons Pakistan, vol. 15, no. 1, pp. 30–33, 2005.
[17]
A. M. Dannenberg Jr., “Immune mechanisms in the pathogenesis of pulmonary tuberculosis,” Reviews of Infectious Diseases, vol. 11, pp. S369–378, 1989.
[18]
A. S. Fauci, “Immunosuppressive and anti-inflammatory effects of glucocorticoids,” Monographs on Endocrinology, vol. 12, pp. 449–465, 1979.
[19]
H. M. Golomb and S. B. Hanauer, “Infectious complications associated with hairy cell leukemia,” Journal of Infectious Diseases, vol. 143, no. 5, pp. 639–643, 1981.
[20]
A. Klossek, C. Dannenberg, M. R. Feuerhahn, and D. K？rholz, “Pulmonary tuberculosis in a child receiving intensive chemotherapy for acute myeloblastic leukemia,” Journal of Pediatric Hematology/Oncology, vol. 26, no. 1, pp. 64–67, 2004.
[21]
A. Hofmeyr, W. F. E. Lau, and M. A. Slavin, “Mycobacterium tuberculosis infection in patients with cancer, the role of 18-fluorodeoxyglucose positron emission tomography for diagnosis and monitoring treatment response,” Tuberculosis, vol. 87, no. 5, pp. 459–463, 2007.
[22]
D. C. Stefan, A. Dippenaar, A. K. Detjen et al., “Interferon-gamma release assays for the detection of Mycobacterium tuberculosis infection in children with cancer,” International Journal of Tuberculosis and Lung Disease, vol. 14, no. 6, pp. 689–694, 2010.
[23]
D. K. Kim, S. W. Lee, C.-G. Yoo et al., “Clinical characteristics and treatment responses of tuberculosis in patients with malignancy receiving anticancer chemotherapy,” Chest, vol. 128, no. 4, pp. 2218–2222, 2005.
[24]
B. Dautzenberg, J. Grosset, J. Fechner et al., “The management of thirty immunocompromised patients with tuberculosis,” American Review of Respiratory Disease, vol. 129, pp. 494–496, 1984.
[25]
M. H. Kaplan, D. Armstrong, and P. Rosen, “Tuberculosis complicating neoplastic disease: a review of 201 cases,” Cancer, vol. 33, no. 3, pp. 850–858, 1974.
[26]
G. H. Lee and J. O. Hah, “Pulmonary tuberculosis in children with leukemia and malignant lymphoma,” Korean Journal of Pediatric Hematology-Oncology, vol. 5, pp. 89–97, 1998.
[27]
Z. Karakas, L. Agaoglu, B. Taravari et al., “Pulmonary tuberculosis in children with Hodgkin's lymphoma,” Hematology Journal, vol. 4, no. 1, pp. 78–81, 2003.
[28]
G. M. Aisenberg, K. Jacobson, R. F. Chemaly, K. V. Rolston, I. I. Raad, and A. Safdar, “Extrapulmonary tuberculosis active infection misdiagnosed as cancer: Mycobacterium tuberculosis disease in patients at a Comprehensive Cancer Center (2001–2005),” Cancer, vol. 104, no. 12, pp. 2882–2887, 2005.
[29]
R. Kar, S. Dutta, and S. Tyagi, “Clinically unsuspected Hodgkin's lymphoma diagnosed primarily from bone marrow trephine biopsy: report of six cases,” Indian Journal of Pathology and Microbiology, vol. 51, no. 2, pp. 186–189, 2008.
[30]
K. Suryanarayan, J. Campbell, and A. E. Eskenazi, “Nontuberculous mycobacterial infections in pediatric acute leukemia,” Journal of Pediatric Hematology/Oncology, vol. 24, no. 7, pp. 558–560, 2002.
[31]
S. Nakamura, Y. Sasajima, T. Koshikawa et al., “Ki-1 (CD30) positive anaplastic large cell lymphoma of T-cell phenotype developing in association with long-standing tuberculous pyothorax: report of a case with detection of Epstein-Barr virus genome in the tumor cells,” Human Pathology, vol. 26, no. 12, pp. 1382–1385, 1995.
[32]
M. E. Falagas, V. D. Kouranos, Z. Athanassa, and P. Kopterides, “Tuberculosis and malignancy,” QJM, vol. 103, no. 7, Article ID hcq068, pp. 461–487, 2010.
[33]
Committee on Infectious Diseases, American Academy of Pediatrics, “Tuberculosis,” in Red Book: 2006 Report of the Committee on Infectious Diseases, L. K. Pickering, C. Baker, S. Long, and J. McMillan, Eds., American Academy of Pediatrics, 27th edition, 2006.
