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.