PMC6126084_01
Gall bladder wall thickening with pericholecystic inflammatory stranding concerning for acute cholecystitis with normal pancreas.
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The CT scan of abdomen revealed intrahepatic biliary ductal dilatation and gall bladder wall thickening with pericholecystic inflammatory stranding with normal pancreas (Figure 1).
Biopsy fragment of right iliac lymph node showing sinus histiocytic aggregates interlaced with lymphocytes and plasma cells. (a) H&E stain, 100x original magnification. Small cells within the lymph nodes, showing morphologic features of plasma cells, characterized by an oval cellular morphologic, and eccentrically placed nuclei. (b) H&E stain, 200x original magnification. Majority of cellular constituents confirmed to be plasma cells, as demonstrated by diffuse reactivity for CD138 by immunohistochemistry. (c) 200x original magnification.
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CD138 (Figure 2(c)). Chromogenic in situ hybridization for kappa light chain (Figure 3(a)) and lambda light chain (Figure 3(b)) showed a mixture of kappa and lambda-bearing cells (approximate kappa to lambda ratio of 3 : 1); this finding suggested that the plasma cells were reactive in nature, arguing against the possibility of a plasma cell neoplasm.
Chromogenic in situ hybridization showing a mixture of kappa-bearing plasma (a) and lambda-bearing plasma (b) cells, with an approximate kappa to lambda ratio of 3-4 to 1, appropriate for a physiologic/reactive phenomenon, without evidence of obvious restriction. Plasma cells expressed predominantly IgG (c); of these, the majority (over 60%) were immunoreactive for IgG4 (d) (200x original magnification).
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CD138 (Figure 2(c)). Chromogenic in situ hybridization for kappa light chain (Figure 3(a)) and lambda light chain (Figure 3(b)) showed a mixture of kappa and lambda-bearing cells (approximate kappa to lambda ratio of 3 : 1); this finding suggested that the plasma cells were reactive in nature, arguing against the possibility of a plasma cell neoplasm. Additional immunohistochemistry showed that the plasma cells present expressed predominantly IgG (Figure 3(c)); of these, the majority (over 60%) were reactive for IgG4 (Figure 3(d)).
Top normal-sized pelvic lymph nodes decreased in size in repeat CT (4(b)) compared to previous CT (4(a)). The largest right external iliac lymph node measures 1.8 x 0.7 cm.
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A follow-up CT scan of abdomen after a month revealed significant reduction in the size of his pelvic lymph nodes with largest lymph node measuring 1.8 x 0.7 cm (Figure 4).
Endoscopic retrograde cholangiography showing presence of stricture in the biliary duct pre-ERC (a) compared to post-ERC (b).
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Endoscopic retrograde cholangiography (ERC) performed revealed resolution of stricture (Figure 5).