Case Report
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Apr 18, 2015; 7(5): 814-818
Published online Apr 18, 2015. doi: 10.4254/wjh.v7.i5.814
Unusual case of B cell lymphoma after immunosuppressive treatment for psoriasis
Lorenzo Nosotti, Andrea Baiocchini, Claudio Bonifati, Ubaldo Visco-Comandini, Concetta Mirisola, Franca Del Nonno
Lorenzo Nosotti, Concetta Mirisola, Gastrointestinal and Liver Department, National Institute for Health, Migration and Poverty, 00153 Rome, Italy
Andrea Baiocchini, Ubaldo Visco-Comandini, Franca Del Nonno, Infectious Diseases Department, National Institute for Infectious Diseases “L. Spallanzani”, 00149 Rome, Italy
Claudio Bonifati, Department of Inflammatory Skin Diseases, San Gallicano Dermatologic Institute (IRCCS), 00144 Rome, Italy
Author contributions: All the authors contributed to this paper.
Ethics approval: This case report conforms to Good Clinical Practice and to the World Medical Association Declaration of Helsinki. It has been approved by the institutional review board of National Institute for Health, Migration and Poverty.
Informed consent: The person involved in this case report gave his informed consent prior to his inclusion in the study. Details that might disclose the identity of the subject under study have been omitted.
Conflict-of-interest: None competing or conflicts of interests declared.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Dr. Lorenzo Nosotti, Gastrointestinal and Liver Department, National Institute for Health, Migration and Poverty, via San Gallicano 25a, 00153 Rome, Italy.
Telephone: +39-06-58543642 Fax: +39-06-58543730
Received: October 21, 2014
Peer-review started: October 22, 2014
First decision: December 22, 2014
Revised: January 26, 2015
Accepted: March 18, 2015
Article in press: March 20, 2015
Published online: April 18, 2015

Lymphomas may be induced by the systemic immunosuppressive therapies used to treat psoriasis, such as ciclosporin, methotrexate and tumour necrosis factor (TNF)-α blockers. The biologic agents currently used in psoriasis include alefacept, efalizumab, and the TNF-α antagonists etanercept, infliximab, and adalimumab. Infections and cancer are the main possible consequences of intended or unexpected immunosuppression. We report a 59-year-old man with a history of severe psoriasis vulgaris treated with traditional immunosuppressant drugs followed by anti-TNF-α therapy; the patient was firstly hospitalized for an acute cholestatic toxic hepatitis, which we supposed to be related to adalimumab. The first liver biopsy showed active disease with severe hepatocellular damage caused by heavy lymphocytes infiltrate in portal tracts at in the interface with a not conclusive diagnosis of lymphoproliferative disease. The correct diagnosis of T cell/histiocyte- rich large B cell lymphoma (T/HRBCL) was only reached through a gastric biopsy and a second liver biopsy. T/HRBCL is an uncommon morphologic variant of diffuse large B-cell lymphoma not described until now in psoriatic patients receiving immunosuppressive biologic agents. In psoriatic patients, treated with biologic immunosuppressive agents, the suspect of abdominal lymphoma should always be included as differential diagnosis. Abdominal ultrasound evaluation need therefore to be included in the pre-treatment screening as in the follow-up surveillance.

Keywords: Psoriasis, Tumor necrosis factor-α blocker, Immunosuppressant, Diffuse large B-cell lymphoma, Lymphoma

Core tip: We report a case of a rare T cell/histiocyte- rich large B cell lymphoma localized to liver, gastro-intestinal tract and spleen in a patient with psoriasis treated with traditional immunosuppressant drugs followed by anti-tumor necrosis factor-α therapy. Liver and spleen involvement mimicked at the beginning an inflammatory disease causing a delayed diagnosis of malignancy. We think that abdominal ultrasound evaluation need to be included in the pre-treatment screening as in the follow-up surveillance in psoriatic patients treated with biologic immunosuppressive agents.