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R-CHOP immunochemotherapy associated with symptom resolution and complete metabolic response in a case of intravascular large B-cell lymphomaHigh Fever and High Ferritin May Signal Rare Blood Cancer

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Key Takeaway
Consider multidisciplinary re-evaluation of PET-CT when random biopsies fail in suspected IVLBCL cases.

This study presents a case report and literature review involving a 60-year-old woman diagnosed with intravascular large B-cell lymphoma (IVLBCL), fever of unknown origin, and secondary hemophagocytic lymphohistiocytosis. The intervention consisted of R-CHOP immunochemotherapy. The patient exhibited a diagnostic triad characterized by persistent extreme hyperferritinemia (peak >15,000 ng/mL), markedly elevated LDH (735 U/L), and strikingly high IL-10 (>600 pg/mL). Histopathology confirmed IVLBCL with CD20+ tumor cells within vascular lumina.

After treatment, the patient demonstrated rapid symptom resolution and a complete metabolic response on follow-up PET-CT. Safety data, including adverse events, serious adverse events, discontinuations, and tolerability, were not reported. The study limitations note that interpretation is confounded by secondary HLH and requires prospective validation. No funding or conflicts of interest were reported.

The diagnostic triad may serve as a useful diagnostic clue. Multidisciplinary re-evaluation of PET-CT is essential for definitive diagnosis when random biopsies fail. Given the confounding factors and lack of prospective validation, these findings should be interpreted with caution in similar clinical scenarios.

Doctors examined a 60-year-old woman with a severe fever that had no clear cause. She had extremely high levels of ferritin, lactate dehydrogenase, and the immune protein IL-10. These markers are often seen in serious inflammatory conditions, but in this case, they pointed to a rare form of blood cancer called intravascular large B-cell lymphoma.

Tissue samples confirmed the presence of cancer cells inside the blood vessels. The patient then received R-CHOP immunochemotherapy. Her symptoms improved quickly, and follow-up scans showed a complete metabolic response with no signs of the disease remaining.

This single case report highlights that a specific combination of lab results can serve as a useful diagnostic clue. However, because the patient also developed a secondary inflammatory condition, it is difficult to say for sure if the lab pattern alone caused the diagnosis. More research is needed to confirm these findings in other patients. When standard biopsies fail to find cancer, doctors should consider re-evaluating PET-CT scans and these specific lab markers to reach a definitive diagnosis.

What this means for you:
A specific lab pattern may help diagnose rare blood cancer when standard tests fail, but more research is needed.

Study Details

Study typeCohort
EvidenceLevel 3
PublishedApr 2026
View Original Abstract ↓
ObjectiveTo highlight the diagnostic value of the ferritin-LDH-IL-10 triad and image-guided targeted biopsy in intravascular large B-cell lymphoma (IVLBCL) presenting as fever of unknown origin (FUO), with a review of relevant literature.MethodsWe present a case of a 60-year-old woman with a 10-month history of cough, progressive fever, and weight loss. We retrospectively analyzed her clinical course, laboratory profile, imaging findings, and histopathological results, and reviewed the relevant literature on IVLBCL diagnosis.ResultsExtensive initial investigations including multiple biopsies (bone marrow, colon, skin) and imaging were nondiagnostic. Persistent extreme hyperferritinemia (peak >15,000 ng/mL), markedly elevated LDH (735 U/L), and strikingly high IL-10 (>600 pg./mL) formed a diagnostic triad raising suspicion for IVLBCL. Re-review of PET-CT identified a subtle pulmonary FDG-avid focus (SUVmax 3.0), guiding video-assisted thoracoscopic wedge resection. Histopathology confirmed IVLBCL with CD20 + tumor cells within vascular lumina. The patient subsequently met criteria for secondary hemophagocytic lymphohistiocytosis. R-CHOP immunochemotherapy achieved rapid symptom resolution and complete metabolic response on follow-up PET-CT.ConclusionThe triad of extreme hyperferritinemia, elevated LDH, and markedly increased IL-10 may serve as a useful diagnostic clue to raise suspicion for IVLBCL in FUO patients, though its interpretation is confounded by secondary HLH and requires prospective validation. When random biopsies fail, multidisciplinary re-evaluation of PET-CT to identify subtle targets for image-guided biopsy is essential for definitive diagnosis. Early recognition of this triad and adoption of a hypothesis-driven biopsy strategy can significantly improve diagnostic outcomes in this elusive lymphoma.
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