Oligosymptomatic B cell lymphoma presenting as an ANA-positive polyarthritis with PET/CT full-body infiltration

Connective tissue diseases have a higher risk of diffuse large B-cell lymphoma [1]. Typically, at presentation, B symptoms are prominent and easily recognizable [2]. This is the case of a 60-year-old patient from Bolivia who initially presented with nausea, jaundice, and general malaise evolving over 1 week. Initially was managed as a suspected Hepatitis A infection, with elevated transaminases and bilirrubin, and general malaise. Decrease in jaundice was seen after treatment with hydration and analgesia. Gastrointestinal symptoms persisted over the following months. Further study with full body CT scan revealed hydronephrosis and benign prostatic hyperplasia with increased prostate size and elevated total prostate-specific antigen. With no improvement, and the emergence of new hand and knee arthritis and stiffness, an immunological study was requested, which revealed ANA 1/80 AC-4 pattern along with a GP210 positive panel of 23 ANA antigens. Our patiente travelled to Chile for further evaluation, presenting with new pronounced sicca symptoms, hand arthritis, diffuse pruritus, and painful skin with induration in the gluteal region. New immunological study showed ANA 1/320 AC-4 pattern, GP210 positive at medium titers, high IgM levels, low C3, and CD25s at 5062 (average value 623). PET-CT revealed diffuse uptake in all quadrants with elevated SUV values and reduced usual brain uptake due to contrast relocation. Skin biopsy showed lymphocytic infiltration and pleural fluid, and hematological studies demonstrated that B-cell infiltration was consistent with diffuse large B-cell lymphoma. Successful treatment with polatuzumab vedotin plus rituximab, gemcitabine, and oxaliplatin was initiated. …