BMJ  2004;328:944 (17 April), doi:10.1136/bmj.328.7445.944

Clinical review

Interactive case report

A 66 year old woman with breathlessness: case outcome

¹ Royal Victoria Hospital, Dundee DD2 1SP, ² Ageing and Health, Division of Medicine and Therapeutics, Ninewells Hospital, University of Dundee, Dundee DD1 9SY

Five weeks ago (20 March, p 698) we described the case of Mrs Dempsey, who was investigated for suspected heart failure. Her symptoms did not improve after initial treatment, and she had further investigation to determine the cause of her bilateral pleural effusions (27 March, p 758). We then suspected an underlying malignancy, and she had computed tomography to assess her chest and extrapulmonary structures (fig 1). This showed large bilateral effusions associated with widespread mediastinal, axillary, and abdominal lymphadenopathy. The likely diagnosis was now advanced lymphoma.

This right axillary node, which had not been detected on previous examinations, was clearly palpable and a biopsy sample was taken. This confirmed the diagnosis of lymphoma. Immunohistochemistry results were in keeping with a grade III follicular B cell non-Hodgkin's lymphoma. Once the biopsy results were available, Mr and Mrs Dempsey were told about the diagnosis of lymphoma at an outpatient appointment, and she was transferred to the haematology unit.

Her effusions were drained and the fluid again contained abundant mature lymphoid cells. Immunophenotyping showed reactive T cells but 35% CD20 positive clonal B cells, similar to the appearances found in the axillary node tissue. These features were in keeping with lymphoma in the pleura. Because of the extensive nature of her incurable low grade lymphoma and her debilitating symptoms, she accepted chemo therapy with cyclophosphamide, vincristine, and prednisolone in an attempt to control the progression of the disease and limit the recurrence of pleural fluid.

Despite initial pancytopenia and neutropenic sepsis, she has tolerated three cycles of chemotherapy. Currently she reports feeling well in herself and gets breathless only when walking up slopes. Her last chest radiograph showed resolution of her effusions and re-expansion of her lungs (fig 2).

The prevalence of congestive heart failure in women aged 60-69 is 25 per 1000,¹ compared with an incidence of non-Hodgkin's lymphoma of 140 per million population.² Five year survival is 45% for non-Hodgkin's lymphoma² and 38% for women with congestive heart failure.³

---

This is the final part of a three part case report, which describes the outcome and summarises the comments made by readers during the case presentation

Competing interests: None declared.

References

1. Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Heart Study. J Am Coll Cardiol 1993;22(suppl A): 6-13A.[ISI][Medline]
2. National Cancer Intelligence Centre, Office for National Statistics, on request, October 2002.
3. Ho KK, Anderson KM, Kannel WB Grossman W, Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation 1993;88: 107-15.[Abstract/Free Full Text]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Related Articles

A 66 year old woman with breathlessness: case progression

Douglas Lowdon and Marion McMurdo
BMJ 2004 328: 758. [Extract] [Full Text] [PDF]

A 66 year old woman with breathlessness: case presentation

Douglas Lowdon and Marion McMurdo
BMJ 2004 328: 698. [Extract] [Full Text] [PDF]

Rapid Responses:

Read all Rapid Responses

axillary node now appears: any comment on raised JVP?

Ramakant sharma
bmj.com, 19 Apr 2004 [Full text]

Learning Points

Ashok Chandra
bmj.com, 19 Apr 2004 [Full text]

Importance of Clinical Signs

Abdullah A Mohammed
bmj.com, 19 Apr 2004 [Full text]