A 34-year-old black woman from the Midwest (born in Ghana) has a recent history of nausea/vomiting, serum Ca2+ level of >14 mg/dL (normal limit = 8.9-10.1 mg/dL), and low-normal PTH levels. She improved with corticosteroids. Soon after (while on steroids), she developed a vesicular rash on her buttocks that tested positive for HSV-2. Despite treatment, the rash proceeded down her legs (Figure 1). Brain MRI showed enhancement in her meninges and pons. PET scan showed moderate uptake in her inguinal lymph nodes. As her work-up was pending, she suffered brief bradycardic spells with loss of consciousness and then arrested. During her unsuccessful resuscitation, she had frank blood coming out of her NG tube and a bedside hematocrit of 16% (normal limit = 34.9-44.5%). Autopsy revealed hemoperitoneum (>2 L) and intrapulmonary hemorrhage without a clear source. She had atypical cells involving her meninges/brain, inguinal lymph nodes, liver, lung, kidney, and rectum (Figure 2). Her bone marrow was unremarkable, and peripheral blood showed 2% involvement by atypical cells. These atypical cells were positive for CD3 and CD4 and negative for CD7, CD8, CD20, CD21, and CD30.
Justin Juskewitch, M.D., Ph.D.
Resident, Division of Anatomic and Clinical Pathology
Mariam (Priya) Alexander, M.D.
Consultant, Division of Anatomic Pathology
Assistant Professor of Laboratory Medicine and Pathology,
Mayo Clinic College of Medicine