Management of a Case of Lymphoplasmacytic Lymphoma Associated with Salt Loosing Nephropathy

A 57 year old non diabetic but hypertensive male was referred to us with fever, weight loss and low backache. On examination he was found to have mild splenomegaly (2cm) and small (pea sized) right inguinal lymph node. His blood revealed Hb level of 8.4 gm/dl, total count of 5300/cumm with lymphocytosis (65%) and a platelet count of 1.1 lacs/cu mm. Direct coombs test was positive. Total protein was 8.5mg/dl with globulin of 2.9mg/ dl, other biochemical parameters were within normal limit. Serum protein electrophoresis (SPE) and serum free light chain assay revealed kappa light chain 6.31 mg/dl and lambda light chain 0.49 mg/dl with kappa lambda ratio of 12.88 which was suggestive of kappa myeloma disease. His bone marrow aspirate shows hypercellularity with medium sized atypical lymphoid cells with clumped chromatin. Some lymphoid cells with eccentric nuclei noted along with 3% plasma cells (Figure.1). Bone marrow biopsy revealed a hypercellular marrow diffusely infiltrated by small to medium size round to elongated lymphocytes with dense chromatin suggestive of a lympho-proliferative disorder (Figure 2). Flow Cytometric analysis on marrow aspirate revealed 44% cells in the lymphoid region out of 100,000 gated events. The cells were an admixture of about 38% B cells, 54% T cells & 8% NK cells.