A 75-year-old women had a sudden onset of fever on February 7, 2019, with a maximal temperature of 37.9℃, accompanied by runny nose, headache, fatigue, dry mouth, decreased appetite and mild drowsiness. The patient lived in Liaoning Province and newly came to Hainan Province one week ago. Except a history of hypertension for 20 years, she had no other specific diseases or familial medical history. She visited a local clinic in Hainan Province on February 9, 2019. Blood tests showed WBC 18.76 × 109/L, Hb 108 g/L, PLT 35 × 109/L, IgA 1290 mg/dl, IgM 71 mg/dl, IgG 2690 mg/dl, IgE 873 IU/ml. Bone marrow cytology and peripheral blood smear showed plasmacytosis, with proplasmacytes accounting for 26% and 23% of all nucleated cells respectively. With a preliminary diagnosis of plasma cell leukemia, she was admitted to Beijing Hospital on February 14, 2019. The vital signs were body temperature 36℃, heart rate 80/min, respiratory rate 18/min, and blood pressure 120/80 mmHg. Physical examination revealed palpable lymph nodes in the neck, and no tenderness in the sternum. Upon admission, hematologic tests revealed gradually increased WBC with progressively decreased Hb and PLT, which is summarized in Table 1. On February 27, the patient presented diffuse bleeding points of both lower limbs with nasal bleeding. Blood biochemistry showed Cr 76 µmol/L, LDH 364 U/L, Fer 597 ng/ml, β2-MG 12.33 mg/L, ESR 102 mm/hr, CPR 1.5 mg/dl, PCT 0.07 ng/ml, PT 18.7 s, D-Dimer 542 ng/ml. Immunofixation by electrophoresis revealed increased immunoglobulin: IgA 1210mg/dl, IgM 209 mg/dl, IgG 4990 mg/dl, IgE 429 IU/ml. Proteinuria was observed including albumin, α1-MG, β2-MG, and immunoglobulin light chains without Bence Jones protein. Besides, Hainan flow cytometric immunophenotyping of bone marrow revealed that the increased plasma cells were not monoclonal——the intracellular kappa/lambda light chain was expressed in a non-restrictive way. Since admission, several cytological examinations had been performed, and certain amounts of abnormal plasma cells were found in both bone marrow and peripheral blood, which is shown in Table 2. Combined with above factors, the primary diagnosis was reactive plasma cell disease. To figure out the behind reason, screening tests of infectious diseases, such as CMV and EBV, autoantibody profile and tumor markers had been done, and there were no positive findings. PET/CT revealed multiple lymphadenopathies with partial interfusion and SUVmax of 29.8. On February 28, the patient underwent left supraclavicular lymph node biopsy, after which, chest symptoms such as short of breath and moist rales began to appear. Blood tests showed WBC 17.87 × 109/L, Hb 71g/L, PLT 26 × 109/L, Fbg 0.94 g/L, PT 24.1 s, APTT 32.1 s, D-Dimer 847 ng/ml, and increased myocardial enzyme with maximal cTnI of 1.87 µg/L. ECG revealed inverted T wave of V2 and V3. Echo demonstrated SWMA of the anterior wall and interventricular septum. Thus, NSTEMI accompanied with ALHF was considered with or without DIC. Vasodilators, diuretic, plasma transfusion and other supportive medications were administered to the patient. On March 1, the patient presented with atrial fibrillation and recovered after treatment with sildenafil, atenolol and amiodarone. Soon afterwards, she got conscious disturbance, acute renal failure with transient oliguria and polyuria, hypernatremia, kaliopenia and metabolic acidosis with gradually decreased peripheral blood oxygen saturation. Non-invasive ventilator-assisted ventilation was administered on March 3. On March 5, return of lymph node biopsy results demonstrated a hint of AITL with plasmacytosis (Fig. 1). On March 6, the results of IgM and IgG antibodies for HTNV with ELISAs returned positive. Eventually, a diagnosis of HFRS was reached. However, the patients died of cardiogenic shock caused by reoccurrence of myocardial infarction at midnight on March 6, 2019.
Table 1
Laboratory tests of the patient on admission day 1, day 10 and day15
Laboratory tests | Day 1 | Day 10 | Day 15 | Normal range |
WBC (109/L) | 7.75 | 11.04 | 60.55 | 3.5–9.5 |
Hb (g/L) | 100 | 87 | 63 | 110–150 |
PLT (109/L) | 88 | 35 | 7 | 125–350 |
Table 2
Results of cytological examinations upon admission
Cytological examinations | Beijing Hospital | Clinical Consultancy |
BM cytology | Proplasmacytes accounting for 34%. | Myeloma cells accounting for 16.5%. |
PB cytology | Plasma cells accounting for 11%. | Myeloma cells accounting for 24%. |
FCI of BM | Polyclonal plasma cells accounting for 20.32%, mainly expressing CD38, CD138, CD19, CD27, HLA-DR, not expressing CD56. | Polyclonal plasma cells accounting for 12.92%, mainly expressing CD38, CD138, CD19, CD27, not expressing CD20, CD56, CD117. |
FCI of PB | Polyclonal plasma cells accounting for 3.22%, mainly expressing CD38, CD138, CD19, CD27, CD81, HLA-DR, not expressing CD56, CD20, CD117. | |