MEDICAL  ILLUSTRATION

Paraneoplastic Arthritis in a Patient with Non-Hodgkin’s 
Lymphoma

Guntur Darmawan, Indra Wijaya, Laniyati Hamijoyo, Trinugroho H. Fadjari
Department of Internal Medicine, Faculty of Medicine, University of Padjadjaran – Hasan Sadikin Hospital, 
Bandung, Indonesia.

Corresponding Author: 
Guntur Darmawan, MD. Department of Internal Medicine, Faculty of Medicine Padjadjaran University – Hasan 
Sadikin Hospital. Jl. Pasteur no. 38, Bandung, Indonesia. email: guntur_d@yahoo.com.

Figure 1. Left neck mass before chemotherapy Figure 2. Bilateral joint swelling before chemotherapy

Figure 3. Shrinkage of the mass after first cycle of 
chemotherapy

Figure 4. Improvement of joint swelling after first cycle of 
chemotherapy

267Acta Med Indones - Indones J Intern Med • Vol 49 • Number 3 • July 2017



Guntur Darmawan                                                                                                                      Acta Med Indones-Indones J Intern Med

Paraneoplastic syndromes are a group of 
disorders associated with benign or malignant 
tumors but not related to mass effect or invasion 
directly. Paraneoplastic syndromes may affect 
any organic system of the human body, such 
as endocrine, neurologic, dermatologic, 
hematologic, rheumatologic. Paraneoplastic 
rheumatic syndromes are not quite common, 
about 7-10% of paraneoplastic syndromes, and 
may mimic rheumatic diseases.1,2 We present an 
interesting case of paraneoplastic arthritis in a 
woman with non-Hodgkin’s lymphoma.

A-45-year-old non-smoker female presented 
to our institution with swollen joints and 
enlargement of lymph nodes on her neck. She 
had a history of recurrent tonsillitis in January 
2016 and underwent bilateral tonsillectomy. 
Histologic review of the right tonsil was consistent 
with chronic tonsillitis while the left tonsil 
demonstrated aggressive type of non-Hodgkin’s 
lymphoma. She refused chemotherapy and 
remained well until June 2016, when she began 
to complain swelling, stiffness, and pain of her 
joints. She sought consult several times at medical 
clinics and treated with analgesics for arthritis. 
There was no improvement, and the patient even 
developed difficulty in performing daily activities 
due to progression of the pain and stiffness. 
Meanwhile, she noticed slow-growing, non-tender 
left neck mass. She also reported weight loss, low 
grade fever, and decreased in appetite. Physical 
examination revealed firm, non-tender left neck 
mass, 8 x 5 x 2 cm in size with intact overlying 
skin. There were symmetrical bilateral finger 
joints swelling with limited range of motion due 
to pain (Figure 1 and Figure 2). Chest x-ray 
showed enlarged right paratracheal lymph nodes 
and x-ray of the hands showed neither erosion nor 
lytic lesion. Abdominal ultrasound and cardiac 
echocardiography result were essentially normal. 
Rheumatoid factor, hepatitis B antigen and 
antibodies for hepatitis C, HIV were negative. She 
then received chemotherapy with CHOP regimen 
(cyclophosphamide, vincristine, doxorubicin, 
and prednisone). There were improvement of 
joints complain and shrinkage of tumor after 
the first cycle of chemotherapy (Figure 3 and 
Figure 4). Currently, she is still undergoing the 
chemotherapy on schedule.

The relationship between malignancy and 
rheumatic diseases is complex. The pathogenesis 
of paraneoplastic rheumatic syndromes are not 
fully understood, involving a number of factors 
such as cytokines, hormones, peptides, and other 
mediators secreted by tumor.3-5 Paraneoplastic 
rheumatic syndromes are not as frequent as 
paraneoplastic endocrine syndromes and often 
difficult to differentiate them from primary 
rheumatologic diseases.6,7 It may precede, occur 
simultaneously, or develop after the diagnosis 
of the neoplasm. Medical history plays an 
important role in establishing the diagnosis 
since there is no consensus on when a patient 
with rheumatological complain should be 
screened for possible underlying malignancy. 
Our patient was initially diagnosed as primary 
rheumatic disease for her joints despite having 
recent history of lymphoma. In 2 case series 
reported by Morel and Kisacik, around 10% of 
paraneoplastic arthritis was due to lymphoma.2,7 
Clinical presentation of our patient might mimic 
rheumatoid arthritis. It fulfilled the clinical factors 
of rheumatoid arthritis ACR/EULAR diagnosis 
criteria with a total score of 6 (more than 10 joints 
and more than 6 weeks duration of signs and 
symptoms).8 The diagnosis may be a dilemma, 
since many rheumatic diseases especially those 
with autoimmune phenomena may increase the 
risk for malignancy. Rheumatoid arthritis had 
been reported to increase the risk of developing 
lymphoma.9,10 However, the involvement of the 
distal interphalangeal joints, non-erosive joint 
on x-ray, negativity of rheumatoid factor made 
rheumatoid arthritis less favored and finally, a 
successful response to chemotherapy reinforced 
the diagnosis of paraneoplastic arthritis.

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Vol 49 • Number 3 • July 2017                                         Paraneoplastic arthritis in a patient with non-hodgkin’s lymphoma

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