Hypercalcemia in T-Cell/Histiocyte-Rich Large B-Cell Lymphoma: An Unusual Presentation of a Rare Disease and Literature Review.

T-cell/histiocyte-rich large B-cell lymphoma (THRLBCL) is an extremely rare morphologic subtype of diffuse large B-cell lymphoma (DLBCL), accounting for only 1-3% of total cases. It is considered an aggressive lymphoma with a poor prognosis. Hypercalcemia has been described as an uncommon presenting symptom of patients with DLBCL in several case reports. Here, we report an unusual case of severe hypercalcemia in a patient who was ultimately diagnosed with T-cell/histiocyte-rich B-cell lymphoma. A 69-year-old male patient presented to our hospital with nausea, vomiting, weakness and unintentional weight loss. His initial blood tests showed a serum calcium level of 16.1 mg/dL and serum creatinine level of 3.25 mg/dL. He had high intact parathyroid hormone (PTH, 6.8 pg/mL), mildly elevated 25-hydroxyvitamin D and serum PTH-related peptide (PTHrP). To exclude malignancy, computed tomography (CT) scans of the chest, abdomen and pelvis were performed which were unremarkable. A bone marrow biopsy was performed to detect any hidden hematologic malignancy which showed large mononuclear cells with prominent nucleoli and occasional Reed-Sternberg cells, consistent with the diagnosis of THRLBCL. Subsequent positron emission tomography demonstrated diffuse fluorodeoxyglucose (FDG) uptake. This case reports a unique presentation of a rare subtype of non-Hodgkin's lymphoma. We highlight the importance of pursuing a thorough workup for causes of hypercalcemia as well as understanding the underlying mechanisms of severe hypercalcemia in malignancy.