Hypercalcaemia and angioimmunoblastic lymphadenopathy

A 57-year-old woman presented in November 1978 with a two-month history of intermittent fever, an evanescent non-pruritic rash, loss of 10 kg, and generalised lymphadenopathy and hepatosplenomegaly. Haemoglobin concentration was 7 8 g/dl, white cell count 316 x 109/1 (31 600/mm3), and platelet count 142 x 109/1. Erythrocyte sedimentation rate was 102 mm in first hour (Westergren), and Coombs test result was positive. Cold agglutinin titre was over 1/1020, and serum immunoglobulin concentrations showed a raised IgM value (2 5 g/l). Blood urea, creatinine, electrolyte, calcium, and phosphate concentrations were normal, as was serum alkaline phosphatase activity. Lymph node biopsy showed findings consistent with angioimmunoblastic lymphadenopathy, with an infiltrate of immunoblasts and plasma cells amidst small-vessel proliferation and amorphous acidophilic interstitial material. In January 1979 the patient complained of increasing lethargy and nocturnal sweats. Red cells treated with chromium-51 showed a half life of eight days (normal 26-30 days). Prednisolone 40 mg/day was initiated, and in early February she had an episode of haematemesis and melaena. Endoscopy showed multiple gastric and duodenal ulcers, which on biopsy showed the histological changes of a mucosal infiltrate, consisting of sheets of large pleomorphic lymphoid cells with pyroninophilic cytoplasm, consistent with immunoblastic sarcoma. She was noted to be hypercalcaemic, with a blood concentration of 3-5 mmol/l (14-0 mg/100 ml). The figure shows her subsequent clinical course. Despite forced saline diuresis and intermittent