A Rare presentation of a Lymphoma in a young girl as Acute Kidney Injury and with Neurological Involvement

A 20 yrs old girl presented with high grade intermittent fever,head ache, vomiting and swelling on both sides of neck for 2 weeks.Empirical ATT started. After a week she developed edema legs, oliguria and found to have renal failure.Examination showed Pt was febrile, had anemia ,bilateral multiple cervical and axillary lymphadenopathy splenomegaly.Investigation showedTrace proteinuria,no active sediments Hb 10.8gm,Total count 14,000cu.mm,Serum creatinine 4.8mgdl withraised LDH.FNAC of nodes attempted,failed.CXR Mediastinal Widening.USG abd- splenomegaly with Bilateral enlarged kidneys with multiple wedged shape hypoechoeic areas present. Two days later she developed BL LMN facial palsy,Bulbar muscle weakness with Quadriparesis .Started on iv methyl prednisolone 1 g for 3 days.Improved .. CSF analysis - numerous lymphocytes with large lymphoid cells( 80 percent smudge cells)- lymphocytic leukaemia with CNS involvement. CT MRI brain showed lymphomatous infiltration in base of skull and dorsal spine.Rapid regression of lymph nodes, after pulse steroid therapy precluded tissue diagnosis. Kidney biopsy Patchy interstitial lymphoid infiltrates with millacute tubular necrosis .Immunohistochemistry of renal biopsy showed Atypical T-cell lymphoid infiltrate most consistent with TLymphoblastic Lymphoma leukemic Infiltrate. Started on chemotherapy with vincristine and dexamethasone. Meanwhile pt developed sudden respiratory difficulty and intubated and on respiratory support.She was treated with intrathecal chemotherapy. Inspite of chemotherapy, her condition deteriorated and succumbed. Diagnosis- Lymphoblastic Lymphoma Stage 4 Acute kidney injury ATN Lymphomatous Infiltration of Kidneys.Disseminated disease with CNS involvement.