First Post

NEJM 2008;359:2707-18.

Exciting. My first post. Oh, what to write about?

Well, one of things I want to get out of this blog is putting down on "paper" some of the interesting lessons to be learned from the New England Journal of Medicine (NEJM). I feel that this periodical is so valuable for learning, whether it be clinical- (Pathology, Internal Medicine, Surgery, Pediatrics) or research-based. Since my medical school days I've actually felt excited (read: I'm a geek) when the newest issues are published online, each Wednesday. I usually turn first to the Case Record of the week where they present, in a clinicopathological correlation (CPC)-type approach, the latest interesting case from their hospital's experience. It gives the reader a chance to come up with her own differential diagnosis based on the history, presenting lab findings, and imaging studies. Then, experts who managed the case run through it with their personal approach, citing important studies and algorithms to approaching similar complaints. For instance, this week is a case of a 51-year-old woman who had anemia and MASSIVE splenomegaly (2.4 kg) [for those of you not acquainted with the usual size of spleens, this is extra super-sized - much bigger than even the liver should be in this sized patient. The usual spleen weighs somewhere around 100-150 gm]. Anyway, there are only a few conditions that result in spleens this big, including the condition that eventually is found to be afflicting this patient. SPOILER ALERT: in the event you haven't seen this case yet, surf away now.

The workup reveals an obvious hematolymphoid process at work, and a bone marrow biopsy is done. Based on the nodular lymphoid bone marrow aggregates and sinusoidal involvement, the immunophenotype (CD19+, CD5/23/10/103-), and histologic appearance in the spleen, the diagnosis was a splenic marginal zone B-cell lymphoma. A counterpart in younger men that also involves the liver (and is of course quite rare) is hepatosplenic gamma delta T-cell lymphoma. Of course, the cell of origin is different but the massive organomegaly is characteristic of both and neither have pronounced peripheral lymphadenopathy. Additional lessons to take away from the case include the workup of hemolytic anemia (Coombs-negative hemolytic anemias do exist) and that Hepatitis C infection is associated with this type of lymphoma. Also, CD103 is a immunomarker that is usually positive in hairy cell leukemia and is variably positive in splenic marginal zone lymphomas.

So, that's what I usually look at first on Wednesdays...looking forward to next week!