Journal of Health and Nutrition Research
Volume 3 No 3 (2024): 216-220
E-ISSN: 2829-9760 (Online)
Published by Media Publikasi Cendekia Indonesia
Journal homepage: https://www.journalmpci.com/index.php/jhnr
DOI: https://doi.org/10.56303/jhnresearch.v3i3.303
A 67-year-old Female with Malignant Splenic Non-Hodgkin
Lymphoma at Banten Regional General Hospital: A Case Report
Adi Rastono1*, Avicenna Muhammad Archie1
Correspondents e-mail:
[email protected] 1 Department of Surgical, Universitas Sultan Ageng Tirtayasa, Serang City, Indonesia
ABSTRACT ARTICLE INFO
CASE REPORTS
Non-Hodgkin's lymphoma (NHL) is a type of lymphoproliferative disorder
primarily involving lymph nodes but can extend to extranodal sites like the Submitted: 20 November 2024
spleen. When NHL originates in the spleen, it is classified as primary splenic Accepted: 10 December 2024
NHL. Due to its unusual presentation, it may resemble other splenic Keywords:
conditions in clinical appearance. In this Journal we report a rare case of Non-Hodkin Lymphoma, Splenic
splenic lymphoma in a 67-year-old female with symptoms of abdominal pain Lymphoma, Splenectomy
in the left quadrant of the abdomen. Multislice Computerized Tomography
(MSCT) scan of the abdomen to axial pelvis section showed splenomegaly Copyright (c) 2024 Authors.
with solid mass et causa suspect splenic lymphoma. The diagnosis of
malignant splenic non-Hodgkin lymphoma can be made after splenectomy Access this article online
and histopathology examination which is consistent with clinical and
radiologic examination found in the Patient.
Quick Response Code
Key Messages:
• This case report highlights the uncommon presentation of malignant splenic non-Hodgkin
lymphoma in a 67-year-old female, underlining the need for early recognition and prompt
diagnosis, especially in cases presenting with systemic symptoms such as fever, night sweats, and
weight loss. The findings emphasize the role of splenectomy and histopathological examination as
definitive diagnostic tools for confirming splenic lymphoma, particularly in patients exhibiting
splenomegaly and related symptoms, as non-Hodgkin lymphoma in the spleen is rare and may
mimic other splenic disease.
Introduction
Lymphomas are a heterogeneous group of malignancies that arise from the clonal proliferation of
lymphocytes, a type of white blood cell at different stages of maturation that consist B- cell, T- cell and
natural killer (NK) (1). Non-Hodgkin lymphoma (NHL) is a neoplasm of the lymphoid tissue originating
from B cell precursors, mature B cells, T cell precursors and mature T cells, Non-Hodgkin Lyphoma and
Hodgkin lymphoma can be differentiated by the presence of Sternberg cell under microscope. If the
Sternberg cell is not present. The lymphomas is classified as Non-Hodgekin (2). Non-Hodgkin lymphoma
by contrast has 60 different classified subtypes (3). These subtypes can be categorised into two groups:
aggressive (60%) and indolent (40%). Diffuse large B-cell lymphoma (DLBCL) is the most common
subtype of indolent NHL, comprising 85% of aggressive and follicular lymphomas (4). The most common
mature B cell neoplasm are Follicular lymphoma, Burkitt lymphoma, diffuse large B cell lymphoma
(DLBCL), Mantle cell lymphoma, marginal zone lymphoma, and primary CNS lymphoma. The most
common mature T cell lymphomas are Adult T cell lymphoma and mycosis fungoides (2).
Patients present with complaints of fever, weight loss, or night sweats, also known as B symptoms.
Systemic B symptoms are more common in patients with a high-grade variant of non-Hodgkin
lymphoma. More than two-thirds of the patient present with painless peripheral lymphadenopathy.
Waxing and waning episodes of lymphadenopathy, along with other symptoms, can be seen in low-grade
lymphoma. Patients have different presentations and vary according to the site involved, in the
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A 67-year-old Female with Malignant Splenic Non-Hodgkin Lymphoma at Banten Regional General
Hospital: A Case Report
gastrointestinal lymphoma usually present with nonspecified symptoms such as epigastric pain or
discomfort, anorexia, weight loss, nausea, or vomiting, occult gastrointestinal bleeding (2).
Non-Hodgkin lymphoma ranked as the 10th most commonly diagnosed cancer, with nearly 553.389
new cases, and the 11thleading cause of cancer-related death in 2022, globally with an estimated
250.679 deaths. Asia is ranked 1st for both incidence of new cases and mortality rate with an estimated
new cases is 235.442 (42,5%), and mortality rate of 121.525 (48,5%). The incidence of new cases of NHL
in Indonesia is ranked 7th with nearly 16.175 new cases and the incidence of mortality is ranked 9th
with total death of 9.440 (5).
Case Description
A 67-year-old female was admitted to the emergency room of Banten Regional General Hospital on
March 26, 2023. The patient came with complaints of abdominal pain in the left quadrant of the
abdomen four days before the admission to the hospital. There was nothing that aggravated or alleviated
the pain. Initially, the patient felt the abdominal pain for the first time around one month ago that
occurred persistently without being affected by time, the patient hasn’t tried to treat the pain and has
never massaged the abdomen, the patient is not taking any regular medication. The patient came to the
surgery polyclinic of Banten Regional General Hospital and was diagnosed with intrabdominal mass with
previous Multislice Computerized Tomography (MSCT) scan of the abdomen to axial pelvis section on
February 09, 2023, showed splenomegaly with solid mass et causa suspect splenic lymphoma (Figure
1). The patient is scheduled to have surgery (Splenectomy). Before the scheduled time the patient felt a
sudden acute pain in the abdomen and was admitted to the emergency room of Banten Regional
Hospital, in the emergency room the patient admitted aggravated abdominal pain four days before the
admission to the hospital with a VAS score of 5. The pain was only felt in the abdomen. The patient
complained of fatigue, nausea, and vomiting after eating, decreased appetite, unexplained fever, night
sweat, and weight loss of approximately 7 kg kilograms, discomfort during defecation, bloody stools (-),
diarrhea (-), there were no complaints during urination. The patient never felt similar symptoms before,
uncontrolled hypertension (+), diabetes mellitus (-), history of pulmonary or heart treatment (-). There
is no one with similar symptoms in the family history, hypertension in the family (-), or diabetes mellitus
(-). The patient does not smoke, or alcohol consumption (-), and the patient is not working.
Physical examination at the time the patient was admitted to the emergency room found the patient
looked moderately ill with blood pressure 180/97 mmHg, heart rate 90x/minute, respiratory rate
20x/minute, temperature 38 °C, anemic conjunctiva, visible mass in the left quadrant abdomen, normal
bowel sound, splenomegaly with Schuffner score of 6, pressure pain on the left quadrant of the abdomen,
there was no sign of abdominal obstruction darm contour (-), darm steifung (-). Supporting examination
on March 26, 2023, found the patient with anemia, leucocytosis, and thrombocytopenia (Table 1). The
patient was transferred to the medical ward on March 27, 2023. Albumin level was checked with the
result of hypoalbuminemia (2.9 g/dL) therefore the patient is treated until the blood routine test and
albumin level is normal and the general condition stabilized to prevent problems during the surgery.
Table 1. Laboratory Test Result
Laboratory Test Result Reference Range Measure Description
Hematology
Blood Routine
Hemoglobin 9.3 11.7 - 15.5 g/dL Low
Hematocrit 27 35 – 47 % Low
Leucocytes 218.8 3.6 – 11.0 10³/µL High
Thrombocyte 77 150 – 440 10³/µL Low
Erythrocyte 3.1 3.8 – 5.2 10⁶/µL Low
Clinical Chemistry
Random Blood Glucose 101 74 – 106 mg/dL Normal
Renal Function
Ureum 33 15 – 40 mg/dL Normal
Creatinine 0.91 0.60 – 1.20 mg/dL
Electrolyte & Blood Gas
Serum Electrolyte
Natrium (Na) 135 135-155 mEq/L Normal
Kalium (K) 4.4 3.5 – 5.0 mmol/L Normal
Chlorida (Cl) 104 95 – 105 mmol/L Normal
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A 67-year-old Female with Malignant Splenic Non-Hodgkin Lymphoma at Banten Regional General
Hospital: A Case Report
The patient underwent a scheduled splenectomy on April 3, 2023. The surgery proceeded smoothly.
A significantly enlarged spleen, measuring 26 x 19.5 x 9 cm, was excised and sent to the histopathology
laboratory for further analysis. During hospital treatment, the patient was given antibiotics ceftriaxone
2gr once daily, omeprazole 40mg once daily, ketorolac 10mg three times a day, and phytomenadione 10
mg three times a day. Postoperative laboratory tests found anemia and leucocytosis (Table 2).
Table 2. Postoperative Laboratory Test Result
Laboratory Test Result Reference Range Measure Description
Hematology
Blood Routine
Hemoglobin 10.1 11.7 - 15.5 g/dL Low
Hematocrit 31 35 – 47 % Low
Leucocytes 109.0 3.6 – 11.0 10³/µL High
Thrombocyte 327 150 – 440 10³/µL Normal
Erythrocyte 3.6 3.8 – 5.2 10⁶/µL Low
Figure 1. Multislice Computerized Tomography (MSCT) (Non-contrast)
The histopathological examination concluded that the spleen showed evidence of non-Hodgkin
malignant Lymphoma. The patient was discharged from the hospital on April 8, 2023, in good general
health. They were fully alert, with stable vital signs, a balanced diet, minimal complaints, and no issues
with bowel movements. They were prescribed home medications, including Levofloxacin 750 mg once
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A 67-year-old Female with Malignant Splenic Non-Hodgkin Lymphoma at Banten Regional General
Hospital: A Case Report
daily, Omeprazole 20 mg once daily, and Paracetamol 500 mg three times a day.
Discussion
This case describes the classic presentation of malignant splenic non-Hodgkin lymphoma in a 67-
year-old female. The non-Hodgkin lymphoma was diagnosed based on splenectomy which was then
brought to the histopathology laboratory, this is the Gold Standard for diagnosing non-Hodgkin
lymphoma (2). Anamnesis found the patient complaints of abdominal pain in the left quadrant of the
abdomen and showed of systemic B Symptoms such as unexplained fever, night sweat, weight loss
followed by fatigue, nausea and vomiting after eating, decreased appetite, discomfort during defecation
without bloody stools. The presence of B symptoms is common in patients in non-Hodgkin Lymphoma
(6,7).
Physical examination found a visible mass in the left quadrant abdomen, normal bowel sound,
splenomegaly with a Schuffner score of 6, and pressure pain on the left quadrant of the abdomen
followed by uncontrolled hypertension with blood pressure 180/97 mmHg. Laboratory findings showed
normocritical normochromic anemia (Hb 9.3 g/dL), leucocytosis (218,8 10³/µL), thrombocytopenia (77
10³/µL) and hypoalbuminemia (2.9 g/dL). Previous MSCT scan of the abdomen to axial pelvis section
showed splenomegaly with solid mass et causa suspect splenic lymphoma. Histopathological
examination from an excised spleen sample measuring 26 x 19.5 x 9 cm concluded that the spleen
showed evidence of non-Hodgkin malignant Lymphoma.
B-cell lymphomas involving the spleen may be primary splenic lymphomas that are largely confined
to the spleen or splenic hilar lymph nodes, without evidence of involvement of other sites except bone
marrow and possibly the liver. These lymphomas typically present in a splenomegaly fashion and lack
peripheral lymphadenopathy, such as splenic marginal zone lymphoma. However, Secondary splenic
lymphomas, where the organ is involved as part of generalized disease represents the more common
setting. This distinction is mostly historic and may not be biologically relevant. Most primary splenic
lymphomas are non-Hodgkin lymphomas; Hodgkin lymphoma confined to the spleen is rare. The most
common presenting symptoms include left-sided abdominal pain and systemic symptoms such as fever,
malaise, and weight loss. There are several variably well-defined entities that represent small B-cell
clonal lymphoproliferations involving the spleen, but which do not fall into any of the other types of B-
cell lymphoid neoplasms recognized in the WHO classification (8). Lymphadenopathy was not found in
The MSCT scan of the abdomen to axial pelvis section which led to primary splenic lymphoma.
Postoperative laboratory tests found anemia and leucocytosis and there were no signs of Overwhelming
post-splenectomy infection (OPSI), such as flu-like symptoms and thrombocytopenia. Since splenic
lymphoma is uncommon, additional research is needed to better understand this condition (9).
Conclusion
A 67-year-old female with symptoms of abdominal pain in the left quadrant of the abdomen. The
patient also had symptoms of fatigue, nausea and vomiting after eating, decreased appetite, unexplained
fever, night sweat, and weight loss of approximately 7 kg kilograms, unexplained fever, night sweats,
discomfort during defecation. There were symptoms of anemia characterized by anemic conjunctiva.
Support examination results showed norm-critical normochromic anemia, leucocytosis,
thrombocytopenia, and hypoalbuminemia. Previous MSCT scan of the abdomen to axial pelvis section
showed splenomegaly with solid mass et causing suspected splenic lymphoma. The patient was
diagnosed with Non-Hodgkin Malignant Lymphoma confirmed after the sample sent to the
histopathology laboratory. The patient was discharged from the hospital on April 8, 2023, in good
general condition, fully conscious, good vital signs, good diet, minimal complaints, no complaints during
defecation. The histopathological examination concluded that the spleen showed evidence of non-
Hodgkin malignant Lymphoma.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.
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