Angioimmunoblastic T-cell Lymphoma Presenting With a Neutrophilic Leukemoid Reaction: A Diagnostic Challenge

Abstract

Angioimmunoblastic T-cell lymphoma (AITL) accounts for 1-2% of all non-Hodgkins lymphoma. Patients present with lymphadenopathy, hepatosplenomegaly, polyclonal hypergammaglobulinemia and skin lesions. The presence of rash and neutrophilia in the absence of circulating abnormal lymphocytes in the peripheral blood film leads to a misdiagnosis. A 33-year-old presented with cervical lymphadenopathy with WCC of 104.9 g/dl, maculopapular rash, loss of weight and appetite associated with B symptoms. His peripheral blood film revealed hyperleukocytosis with a neutrophilic leukemoid reaction. Neutrophil alkaline phosphatase (NAP) score was high. Bone marrow aspirate and trephine were suggestive of neutrophilic leukemoid reaction with features of granulocytic hyperplasia with no lymphoid aggregates suggestive of neutrophilic leukemoid reaction secondary to underlying malignancy with a differential of myeloproliferative neoplasm if no reactive causes of granulocytic hyperplasia could be found. A lymph node biopsy was done later and was consistent with AITL. This case illustrates the rare presentation of AITL with a neutrophilic leukemoid reaction in the absence of anaemia, eosinophilia and abnormal lymphoid cells.