This case involves a 59-year-old female patient who presented to the hospital with blood in her urine. She underwent an abdominal ultrasound during which a mass suggestive of a hemangioma (birthmark) was noted. A CT scan was performed which showed a low-attenuation lesion in the liver and moderate swelling of the lymph nodes, raising the possibility of lymphoma. Although it was noted that further PET CT imaging should be conducted to assess the patient for hypermetabolic activity, the patient was instead sent for an MRI. The imaging results were suggestive of hemangioma in the liver and multiple hemangiomas in the vertebral bodies. A follow-up MRI was conducted 6 months later but was also deemed inconclusive. Based on these results, a biopsy was not done and no plan was secured to follow-up on MRI imaging. A few months later, the patient visited her primary care physician with complaints of back pain. She was diagnosed with a herniated disc and given painkillers. One week after beginning the regiment of painkillers, the patient lost all sensation in her legs and had trouble walking. The hospital examined the patient, noted that the cause was sciatica, suggested an MRI, and sent her home. The following day, the patient could not walk. The patient’s primary care physician sent her to get an X-ray and an MRI. The patient was told that a tumor was compressing the spine and was sent for emergent surgery. The patient underwent an emergent decompression posterior laminectomy and was subsequently diagnosed with follicular lymphoma. The patient required ongoing physical therapy and was never able to walk on her own again.
Question(s) For Expert Witness
- 1. How often do you diagnose follicular lymphoma patients?
- 2. What is the usual presentation of these patients in terms of symptoms and acuity?
Expert Witness Response E-006953
I have more than 16 years of clinical experience in outpatient and inpatient internal medicine. In addition, I have diagnosed lymphoma numerous times during my career in internal medicine. Follicular lymphoma is a common variant of lymphoma. In this case, the presence of a mass and lymphadenopathy would have required a definitive diagnostic procedure including advanced imaging (PET-CT) and a surgical biopsy. The usual presentation for patients with Lymphoma is an enlarged lymph node or mass or “B” symptoms such as fevers, night sweats, or unintentional weight loss.