Case 2
A 78-year-old female with CKD stage IV and active warfarin use for VTE was admitted with six weeks of progressive generalized weakness, lethargy, and a few months of functional decline. Pertinent labs on admission include: WBC 3.8 x 109/L, hemoglobin 8.3g/dL, platelets 55 x 109/L, total bilirubin 0.7mg/dL, ESR 120mm/hr, INR 3.2, creatinine 5.5mg/dL, eGFR 9mL/min/1.73m2. Workup was initiated for kidney injury. Several days into admission, her labs worsened to WBC 1.4 x 109/L, hemoglobin 5.5g/dL, platelets 31 x 109/L, ferritin 1316ng/mL, LDH 2289 IU/L, INR 3.4. Peripheral blood smear showed normal morphology of all cell lines. A bone marrow biopsy was planned; however, her overall condition deteriorated rapidly, and she went into shock and respiratory failure. She subsequently had a PEA arrest requiring brief CPR. After ROSC, she was found to be in DIC that was refractory to blood products. Supportive measures such as continuous hemodialysis and pressors were initiated but were ultimately unsuccessful and were followed by her passing. An autopsy showed extensive vascular involvement of all histological sections (bone marrow, liver, kidney, large bowel, pancreas) by large atypical malignant lymphoid cells. Cells were positive for CD20, BCL-2, scattered positive for CD5 and CD10, and negative for BCL-6 and MUM1. The cause of death was multiorgan failure secondary to systemic hemorrhage from coagulopathy due to intravascular lymphoma.