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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Large granular lymphocytic &#40;LGL&#41; leukaemia was described by Loughran et al&#46; in 1985&#46; It is characterized as an unusual heterogeneous disorder with clonal expansion of mature T lymphocytes&#46; Although the cause is unknown&#44; antigenic stimuli responsible for inducing the activation of large granular CD8&#43; effector lymphocytes via different signaling pathways have been implicated&#46; It has been associated with a wide spectrum of signs and symptoms that can be the first or only manifestation of the disease&#44; including asymptomatic periods&#44; splenomegaly&#44; cytopenias&#44; recurrent bacterial infections&#44; B symptoms&#44; hepatomegaly&#44; lymph node involvement&#44; neuropathy and pulmonary hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> In addition&#44; an association has been established between LGL leukaemia and autoimmune diseases&#44; forming part of an entity known as pseudo-Felty&#39;s syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> We report the case of a 62-year-old woman who developed LGL leukaemia 30 years after being diagnosed with seronegative rheumatoid arthritis &#40;RA&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">When she presented to our hospital&#44; the patient was being treated with 5<span class="elsevierStyleHsp" style=""></span>mg prednisone and 150<span class="elsevierStyleHsp" style=""></span>mg ranitidine&#46; On physical examination&#44; she had pale skin and mucous membranes&#44; deformed metacarpophalangeal and interphalangeal joints&#44; and splenomegaly&#46; Her laboratory tests were normal&#44; with the exception of a leukocyte count of 1&#46;82<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#59; neutrophils&#44; 0&#46;877<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#59; iron deficiency anemia&#59; platelets&#44; 139<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#59; complement C3&#44; 70&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; complement C4&#44; 5&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; and positive antinuclear antibodies with a homogeneous pattern&#46; Oral iron therapy and weekly methotrexate were started and her prednisone dose was raised&#46; In view of the clinical course &#40;especially RA and neutropenia&#41;&#44; as well as the presence of splenomegaly&#44; we considered a diagnosis of Felty&#39;s syndrome &#40;FS&#41;&#46; Computed tomography confirmed the splenomegaly and a bone marrow study revealed the presence of an interstitial and nodular infiltrate of T lymphocytes expressing CD3&#44; CD8&#44; T-cell receptor &#40;TCR&#41; &#946;F1&#44; and CD57&#44; suggestive of infiltration by LGL leukaemia&#46; Four months after the initiation of treatment with methotrexate&#44; the patient developed an abdominal wall abscess requiring antibiotic therapy and surgical drainage&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Large granular lymphocytic leukaemia is an uncommon clinical condition&#44; characterized by an indolent&#44; nonprogressive clinical course&#46; The symptoms present during the sixth decade of life&#44; and it affects both sexes equally&#46; It constitutes 2&#8211;5&#37; of all T&#47;natural killer &#40;NK&#41; cell neoplasms&#46; To date&#44; 400 cases have been reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Given the criteria established for LGL leukaemia&#44; which require the presence of clonal expansion of LGL in peripheral blood &#62;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L and&#47;or bone marrow and a study showing the characteristic immunophenotype &#40;CD3&#43;&#47;CD8&#43;&#47;CD57&#43; and&#47;or CD16&#43;&#41;&#44; as well as clonal TCR gene rearrangement&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> we considered a possible diagnosis of this disease&#44; as our findings were consistent with the reported features&#46; In view of the patient&#39;s medical history&#44; we ruled out other conditions like FS&#44; a systemic complication of RA characterized by the triad of RA&#44; persistent neutropenia and splenomegaly&#44; which is closely associated with the HLA-DR4 haplotype &#40;nearly 95&#37; of the patients&#41;&#44; although some authors have suggested that FS and LGL leukaemia associated with RA are expressions of a single entity characterized by LGL proliferation&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;4</span></a> It must also be distinguished from infections&#44; hematologic neoplasms&#44; solid tumors and autoimmune diseases&#46; We consider it of interest to highlight the association between LGL leukaemia and certain autoimmune diseases&#44; including RA&#44; Sj&#246;gren&#39;s syndrome&#44; polymyositis&#44; rheumatic polymyalgia&#44; vasculitis&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> endocrine disorders&#44; celiac disease and autoimmune polyendocrinopathy-mucocutaneous candidiasis-ectodermal dystrophy syndrome&#44; among others&#44; resulting in a condition known as pseudo-Felty&#39;s syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; the diagnosis of LGL leukaemia associated with RA requires a high index of suspicion&#44; based on the connections between patient history and analytical and radiological criteria&#44; as well as the confirmation of a characteristic immunophenotype in peripheral blood and&#47;or bone marrow&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Detailed descriptions of new cases could contribute to the achievement of a better understanding of this condition and to the awareness of the importance of early diagnosis and therapeutic intervention&#46;</p></span>"
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Letter to the Editor
Rheumatoid arthritis and T cell large granular lymphocyte leukaemia: A case report
Artritis reumatoide y leucemia de linfocitos grandes granulares T. A propósito de un caso
María del Mar Herráez-Albendeaa,
Corresponding author
marherraez@gmail.com

Corresponding author.
, María del Castillo Jarilla-Fernándeza, Francisco Jiménez-Burgosb, Elisa Sánchez-Rodriguezc
a Servicio Hematología, Hospital de Santa Bárbara, Puertollano, Ciudad Real, Spain
b Servicio de Anatomía Patológica, Hospital de Santa Bárbara, Puertollano, Ciudad Real, Spain
c Servicio Reumatología, Hospital de Santa Bárbara, Puertollano, Ciudad Real, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Large granular lymphocytic &#40;LGL&#41; leukaemia was described by Loughran et al&#46; in 1985&#46; It is characterized as an unusual heterogeneous disorder with clonal expansion of mature T lymphocytes&#46; Although the cause is unknown&#44; antigenic stimuli responsible for inducing the activation of large granular CD8&#43; effector lymphocytes via different signaling pathways have been implicated&#46; It has been associated with a wide spectrum of signs and symptoms that can be the first or only manifestation of the disease&#44; including asymptomatic periods&#44; splenomegaly&#44; cytopenias&#44; recurrent bacterial infections&#44; B symptoms&#44; hepatomegaly&#44; lymph node involvement&#44; neuropathy and pulmonary hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> In addition&#44; an association has been established between LGL leukaemia and autoimmune diseases&#44; forming part of an entity known as pseudo-Felty&#39;s syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> We report the case of a 62-year-old woman who developed LGL leukaemia 30 years after being diagnosed with seronegative rheumatoid arthritis &#40;RA&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">When she presented to our hospital&#44; the patient was being treated with 5<span class="elsevierStyleHsp" style=""></span>mg prednisone and 150<span class="elsevierStyleHsp" style=""></span>mg ranitidine&#46; On physical examination&#44; she had pale skin and mucous membranes&#44; deformed metacarpophalangeal and interphalangeal joints&#44; and splenomegaly&#46; Her laboratory tests were normal&#44; with the exception of a leukocyte count of 1&#46;82<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#59; neutrophils&#44; 0&#46;877<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#59; iron deficiency anemia&#59; platelets&#44; 139<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#59; complement C3&#44; 70&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; complement C4&#44; 5&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; and positive antinuclear antibodies with a homogeneous pattern&#46; Oral iron therapy and weekly methotrexate were started and her prednisone dose was raised&#46; In view of the clinical course &#40;especially RA and neutropenia&#41;&#44; as well as the presence of splenomegaly&#44; we considered a diagnosis of Felty&#39;s syndrome &#40;FS&#41;&#46; Computed tomography confirmed the splenomegaly and a bone marrow study revealed the presence of an interstitial and nodular infiltrate of T lymphocytes expressing CD3&#44; CD8&#44; T-cell receptor &#40;TCR&#41; &#946;F1&#44; and CD57&#44; suggestive of infiltration by LGL leukaemia&#46; Four months after the initiation of treatment with methotrexate&#44; the patient developed an abdominal wall abscess requiring antibiotic therapy and surgical drainage&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Large granular lymphocytic leukaemia is an uncommon clinical condition&#44; characterized by an indolent&#44; nonprogressive clinical course&#46; The symptoms present during the sixth decade of life&#44; and it affects both sexes equally&#46; It constitutes 2&#8211;5&#37; of all T&#47;natural killer &#40;NK&#41; cell neoplasms&#46; To date&#44; 400 cases have been reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Given the criteria established for LGL leukaemia&#44; which require the presence of clonal expansion of LGL in peripheral blood &#62;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L and&#47;or bone marrow and a study showing the characteristic immunophenotype &#40;CD3&#43;&#47;CD8&#43;&#47;CD57&#43; and&#47;or CD16&#43;&#41;&#44; as well as clonal TCR gene rearrangement&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> we considered a possible diagnosis of this disease&#44; as our findings were consistent with the reported features&#46; In view of the patient&#39;s medical history&#44; we ruled out other conditions like FS&#44; a systemic complication of RA characterized by the triad of RA&#44; persistent neutropenia and splenomegaly&#44; which is closely associated with the HLA-DR4 haplotype &#40;nearly 95&#37; of the patients&#41;&#44; although some authors have suggested that FS and LGL leukaemia associated with RA are expressions of a single entity characterized by LGL proliferation&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;4</span></a> It must also be distinguished from infections&#44; hematologic neoplasms&#44; solid tumors and autoimmune diseases&#46; We consider it of interest to highlight the association between LGL leukaemia and certain autoimmune diseases&#44; including RA&#44; Sj&#246;gren&#39;s syndrome&#44; polymyositis&#44; rheumatic polymyalgia&#44; vasculitis&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> endocrine disorders&#44; celiac disease and autoimmune polyendocrinopathy-mucocutaneous candidiasis-ectodermal dystrophy syndrome&#44; among others&#44; resulting in a condition known as pseudo-Felty&#39;s syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; the diagnosis of LGL leukaemia associated with RA requires a high index of suspicion&#44; based on the connections between patient history and analytical and radiological criteria&#44; as well as the confirmation of a characteristic immunophenotype in peripheral blood and&#47;or bone marrow&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Detailed descriptions of new cases could contribute to the achievement of a better understanding of this condition and to the awareness of the importance of early diagnosis and therapeutic intervention&#46;</p></span>"
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ISSN: 21735743
Original language: English
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