Congresis Iasi 2016

Burkitt’s lymphoma in a child: a

case report

Author: Carmen-Maria Bârsan Co-Author: Farai Nhambasora;

Ionela-Larisa Irimița; Eduard Murãraşu
Scientific Coordinators: Professor Ingrith Miron, MD, PhD, Teaching
Assistant Ancuta Ignat, MD, PhD-student Pediatrics Department,
“Gr.T. Popa” University of Medicine and Pharmacy, Faculty of
Medicine,Iași, Romania
 Chief Complaint
A 6 year old male presents with

• vomiting
• fever (38.5 ° C) .
• abdominal pain
• fatigue
• Diarrhea
 History of
presenting case
Vomiting after eating , Diarhea (sometimes with
melena), symptoms had been persisting for two
weeks.
 History of Previous illnesses

• locomotor and speech disorders in development.

Current Medications : antiepileptic -Timonil (1compr.x3 / day,

every day)- and Milgamma (one vial / day ) Vit B6

Socio economic background : rural home, 4 people in 2 rooms.

No smokers in home,No alcohol consumption.

• Allergies: Non
 General clinical examination.
• General state :poor, patient showed signs of dispnia
and cianosis.
• State of consciousness preserved.
• Facies symmetrical normal complied
• Pale skin and mucous membranes.
• Appendages normally implanted. Normal nails and
hair.
• Height = 110cm, G = 33 kg, BMI = 27.27
• Nutritional status (overweight)
 Systematic Examination

• Adipose tissue well represented

• Ganglionic system:
superficial lymphnodes Not palpable.
Muscular system : Normotonic ,normotrophic,
normokinetic
• Osteo-articular system :seemingly upright, with
the active and passive movements.
• Respiratory: normal chest morphology
,abolished vezicular sounds at the right hemithorax
and the base of left hemithorax.
• Cardiovascular System:chest area of
apparently normal ,with an apex shock on the
junction of the V intersoastal space and
midclavicular line, rhythmic heart sounds and
heart beat, pulsatile bilateral peripheral
arteries,
• AT = 140/100 mmHg.(Stage 1 hypertension)
HR = 136 beats / min (tachycardia).
• Digestive System :
Mobile abdomen with respiratory
movements, relaxed volume.
• palpation on the right flank of the abdomen,
caused pain. Also palpable was an immobile
pseudo tumor formation of ~ 8 cm,

• Liver, biliary and spleen

• Liver 1 cm below the costal margin
• spleen impalpable
 Differential diagnosis

• Abdominal tumor formation

• -Nefroblastoma(Wilms tumor)
• -Apendicites;
• -Neoplasma;
• Liver ptosis
• Liver tumor formation
Labs and Imagistics
 Complete Blood Count
GR 4.63 mil/mm3

Hb 12.2 g/dl
Ht 36.5 %
WBC 12 890 /mm3 ↑
N 11 200 /mm3 ↑
Ly 900 /mm3 ↓
M 770 /mm3
Eo 10 /mm3
B 10 /mm3
Tr 845 000 /mm3 ↑
 Inflammatory Tests
Fibrinogen 353 mg/dl
VSH 42 mm/h ↑
C reactive Protein 94.93 mg/l ↑

• Blood Biochemistry
Sodium 138.6 mmol/l

Potassium 4.99 mmol/l

TGO 42 U/L ↑
TGP 15 U/L
Ureea 30 mg/dl
Glucose 107 mg/dl
Total Blood Protein 58.39 g/l ↓
Blood Creatinine 0.65 mg/dl
GGT 77 U/L ↑
Alkaline Reserve 19.63 mmol/l ↓
• ECG - sinus tachycardia (140 bpm) - where T
rounded and slightly flattened in all
derivations - QT (0.32 s)
Chest radiograph
Right pleurisy in high volume, occupying more than
2/3 of the right hemithorax;
Mild pleurisy on the left ,Widened mediastinum,
bilateral intercleidohilar infiltrative appearance.
• Pleural effusion examination:
• Cytology: pleural fluid with a high volume of numerous
lysed cells, neutrophils 28%, L 2%, 4% macrophages, 66% Blast
(with blue cytoplasm and numerous intracytoplasmic
vacuoles)
• Immunophenotyping: CD19 +, CD10 +, CD20 +, CD22 +,
CD79a +, CD45 +, CD38 +, CD33 +, CD34 +, CD15 +, CD58 +,
CD9 +, CD123 +;
• 50% were identified aberrant B lymphoid cells, intracellular
volume and complexity pronounced suggestive of Burkitt
lymphoma.
• Immunohistochemistry positive cells are IgMs, CD19, CD20,
CD79a, CD10.

• In terms of molecular translocation appears t (8; 14) and

rearrangements of the c-myc gene
• CT:
• mediastinal opacity near the celiac trunk;
• Bilateral pleural effusion, most important right;
• MTS pleural, pericardial, renal, peritoneal and
muscular;
• Solid tumor formation of 10.6 / 10.4 / 13.5 cm on the
right flank and iliac fossa, imprecisely delimited,
which includes ascending colon, surrounded by
important collateral circulation, crossed by several
branches inferior mesenteric vascular network;
• 1/3 medium testicle present in the bilateral inguinal
canal
 Diagnosis

• Using the results from Immunophenotyping

profile,Histology and Appearance of lesions on
CT.
*Intrathoracic tumors

• Sporadic Burkitt lymphoma, STAGE III.

 General Treatment
• Medication for pain
• Tramadol 25 mg x 3 / day;
• Algocalmin x4 1 ml / day;
• Antibiotics
• Tazocin (PIPERACILLINUM + TAZOBACTAMUM) 3.25 mg x 3 / day
• Ciprinol (CIPROFLOXACINE)400 mg / 2;
• Fortum (ceftazidime ) 3g / 3;
• Digestive medication
• Smecta 1plic x2 / day;
• Ranitidine (histamine-2 blockers) 1 f / 2 i.v;
• Controloc (PANTOPRAZOLUM - IPP) 40 mg / day;
• Kreon (Lipaza/ 25 000 Amilaza/ 18 000 Proteaza/ 1 000) 25,000 IU / day;
• To regulate Acidoses
• CaCO3 1 g / 2;
• Transfusions - three days in a row, each 150 ml frozen plasma B III +
• Respiratory
• oxygen;
• aerosols;
• ACC (N-acetyl cysteine) 1 envelope x2 / day.
 Specific treatment
• Chemotherapy according to the scheme:
• Dexamethasone 10 mg / 2 i.v.;
• CTX 200mg;
• Mesna 100mg x3;
• Fluid overload.
 The peculiarity of the case

• - Evolution insidious, sudden onset;

• - Symptoms appeared late in dissemination
multiple organic phase, which gives the
patient a grim prognosis.
W.B.C Flactuations Against N
Day.35

Day.33

Day.31

Day.28

Day.20

Day.13
LYMPH %

Day.10 IG%

Day.7

Day.3

Day.2

Day.1

Normal

82% 84% 86% 88% 90% 92% 94% 96% 98% 100%
 Balancing Disease Complications vs Therapy complications

• COMPLICATIONS OF COMPLICATIONS OF
DISEASE: THERAPY:
• Mechanical myelosuppression;
compression; mucositis;
• bleeding; Digestive: necrotizing
• infections; enteritis;
Tardive: heart, growth,
• Dysmetabolic: SDR.
reproduction;
tumor lysis
secondary
malignancies
.
Thank you!!
 Special thanks to
• Sf Maria Hospital Medics and staff.

Bibliography:
Bellan C, Lazzi S, De Falco G, Nyongo A, Giordano A, Leoncini L (March 2003). "Burkitt's lymphoma: new
insights into molecular pathogenesis".

• Turgeon, Mary Louise (2005).Clinical hematology: theory and procedures. Hagerstown, MD: Lippincott
Williams & Wilkins. p. 283.ISBN 0-7817-5007-5.Frequency of lymphoid neoplasms. (Source: Modified from

WHO Blue Book on Tumour of Hematopoietic and Lymphoid Tissues. 2001, p. 2001.)

• -Dr D.T Anton Pediatrie Notiuni fundamentale