









































Pa
ge

 
1



Pa
ge

 
18

5

American Journal of  Medical 
Science and Innovation (AJMSI) 

Follicular Lymphoma in a Young Male: A Case Report
Ahmed Anaizi1*, Issam Mayhoub Mayhoub1, Said Huwaijah1

Volume 2 Issue 2, Year 2023
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v2i2.2143
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: October 09, 2023
Accepted: November 05, 2023
Published: November 08, 2023

Follicular Lymphoma is an uncommon cancer that involves B-cells in germinal centres. 
Non-Hodgkin’s lymphoma is also significantly represented by follicular lymphoma; different 
morbidity figures are observed in some countries. This case report describes the clinical 
journey of  a 33-year-old man whose shortness of  breath, worsening cough, along systemic 
symptoms culminated in a diagnosed case of  follicular lymphoma. Hepatosplenomegaly 
was observed on clinical examination, and laboratory blood tests showed lymphocytosis 
and significant lymphadenopathy. Quick diagnostic imaging such as Ultrasound and 
X-rays/CT scans was instrumental in determining disease extent. Later, following further 
discussions between a haematologist-oncologists at the tertiary care centre and a definitive 
biopsy of  lymph nodes,, the final diagnosis was affirmed as Follicular lymphoma, Grade 
1A, accompanied by circulating lymphoma cells in the peripheral blood. This incident 
exemplifies the significance of  identifying Follicular Lymphoma at an early stage, conducting 
a thorough evaluation, and involving many medical specialists in treating it. For optimal 
outcomes in patients with follicular lymphoma, timely interventions and tailored treatments 
may be necessary.

Keywords
Follicular Lymphoma, Non-
Hodgkins Lymphoma, 
Lymphadenopathy

1 Department of  Mediclinic, Al Ain Hospital /Al Ain Region, Central District, Abu Dhabi, United Arab Emirates
* Corresponding author’s e-mail: ahmedanaizi011@outlook.com

INTRODUCTION 
FL is a relatively common systemic neoplasm 
characterised by the differentiation of  B cells of  the 
germinal centre (Carbone et al., 2019). This is about 5% 
of  all blood cancers and approximately 20-25% of  new 
cases of  non-Hodgkin lymphomas in Western countries 
(Carbone et al., 2019). FL is the second most prevalent 
lymphoma in the United States, with an estimated annual 
diagnosis of  approximately 14,000 patients(Batlevi 
et al., 2020). Fl exhibits variations in its prevalence 
across regions, with it being less common in Central 
and South America, accounting for 20% of  all non-
Hodgkin lymphomas(Carbone et al., 2019). FL does not 
display a strong prediction for either gender. However, 
its incidence tends to rise with advancing age, with a 
median age at diagnosis of  65 years, rarely manifesting 
in children and adolescents(Batlevi et al., 2020). Although 
there is a slightly increased risk of  FL among individuals 
with affected relatives, the absolute risk remains relatively 
low(Carbone et al., 2019).  FL’s oncogenic journey begins 
in precursor B-cells and culminates in a fully developed 
tumour upon reaching the terminal centre maturation 
stage. The diagnosis of  FL hinges upon histological 
analysis of  a biopsy obtained from affected lymph nodes, 
with preference given to incisional biopsies to facilitate 
grading and transformation assessment(Freedman & 
Jacobsen, 2020). A defining genetic hallmark in the 
majority of  FL cases is the t(14,18) translocation involving 
the igH/bcl-2 genes(Freedman & Jacobsen, 2020). 
Rituximab, often in combination with chemotherapy, 
is effective but not curative for treating FL(Cahill & 
Smith, 2022). Lenalidomide and rituximab provide a 
chemotherapy-free option for both initial and relapsed 
cases(Cahill & Smith, 2022). Replace patients may benefit 

from PI3 kinase inhibitors and anti-CD20 therapy, with 
stem cell transplantation rarely needed(Freedman & 
Jacobsen, 2020).
Our case report seeks to provide valuable insights 
into the challenges and multidisciplinary approaches 
involved in diagnosing and treating this haematological 
malignancy, ultimately contributing to medical knowledge 
and improving patient care in similar cases. 
 
Case Presentation
A 33-year-old male presented on May 30th 2023 at Al 
Ain Hospital /Al Ain Region, Central District - Abu 
Dhabi - United Arab Emirates, with a chief  complaint of  
worsening shortness of  breath over the past four weeks. 
He also reported experiencing a cough that worsened 
when lying flat on the back. The patient reported that 
the shortness of  breath had progressively worsened 
over the last month. Initially, he experienced it only with 
physical exertion, but it advanced to the point where he 
felt shortness of  breath even during minimal activity like 
walking 10 meters. Notably, he observed that the cough 
became more pronounced when he lied down.
Additionally, he reported orthopnea, which was difficulty 
breathing when lying flat , and tachypnea. The patient 
was informed about the cervical lymphadenopathy in 
2019 and was advised, as per the patient’s statement, to 
consult a dentist. Remarkably, over 4.5 years, the patient 
did not seek any medical attention or consult with any 
physician regarding this issue, suggesting a prolonged 
period of  unaddressed concern related to cervical 
lymphadenopathy. 
On initial examination at the hospital, the patient was 
obese and had a pale complexion. He also experienced 
diaphoresis, characterised by excessive sweating. Clinical 



Pa
ge

 
18

6

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 2(2) 185-191, 2023

Figure 1: Laboratory Results

examination revealed that the patient exhibited significant 
sinus tachycardia, with a heart rate exceeding 120 beats per 
minute. Upon auscultation of  the posterior chest, bilateral 
crepitations was noted. The patient’s oxygen saturation 
(SpO2) was measured at 94%. The patient presented 
with generalised lymphadenopathy, observed in both 
sides of  the neck, axillae, and inguinal region. While the 
abdomen was soft to palpation, it appeared distended due 
to significant hepatosplenomegaly. An ECG confirmed 
sinus Tachycardia. Laboratory findings included high 

Figure 2: Peripheral Smear Report

CRP, an ESr of  74, significant lymphocytosis, a white cell 
count of  27,000, and an HB level of  8.1 g/dl. Peripheral 
smear results raised concerns about haematological 
abnormalities (Figure 1).
The peripheral smear report reveals leukocytosis with a 
significant presence of  mature lymphocytes characterised 
by cleaved nuclei and smudged cells, as shown in Figure 
2 below. Platelet counts remain within adequate levels. 
These haematological findings are suggestive of  a clinical 
condition associated with lymphoma.

Urgent diagnostic imaging was undertaken, including 
ultrasound and x-ray examinations, followed by 
subsequent CT scan of  the neck/thorax, abdomen and 
chest. These diagnostic procedures were conducted 
promptly to assess the patient’s medical condition and 
obtain detailed information about the relevant anatomical 
areas. 
The ultrasound of  the upper abdomen shown in 
Figure 3 reveals an enlarged cirrhotic liver measuring 
approximately xxx cm with a nodular echo pattern, 
suggestive of  cirrhosis. The left portal vein is patent with 

normal diameter and the intrahepatic bile ducts and liver 
vasculature appear normal. The gallbladder is normal in 
size, configuration and contour with no gallstones seen. 
The pancreas is clearly visualized due to colonic gas and 
appears normal. The spleen is significantly enlarged, 
measuring approximately 22 cm. Both kidneys are of  
average size and normal sonographic structure with 
clear perinephric facial planes, no renal stones or cysts/
masses seen, and no hydronephrosis. There is significant 
lymphadenopathy noted at the iliac chains bilaterally with 
compression of  the bladder.



Pa
ge

 
18

7

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 2(2) 185-191, 2023

The chest X-ray, as shown in Figure 4 below, showed 
marked enlargement of  both hila in the lungs, primarily 
attributed to lymphadenopathy. Additionally, interstitial 
pulmonary infiltrates were identified in both lung fields, 
suggesting the presence of  abnormal cells within the 
interstitial spaces of  the lungs. Furthermore, extensive 
lymphadenopathy at the iliac chains bilaterally was 
observed, which was causing compression of  the 
bladder and may lead to urinary symptoms. Moreover, 
hepatosplenomegaly was evident, with the liver displaying 
clear enlargement and a nodular echo pattern, particularly 
at the left lobe.
The neck ultrasound assessment (Figure 5) showed 
normal lymph nodes in the neck. The results indicated 
the presence of  numerous enlarged lymph nodes on both 

sides of  the neck. Additionally, there were hypoecholic 
lesions observed within the parotid glands on both sides. 
The preserved fatty hilum within the enlarged lymph 
nodes suggested characteristics typically associated with 
reactive lymph nodes.
The radiographic findings from the CT scan of  the 
chest and thorax, shown in Figure 6 below, showed 
noticeable lymph node enlargement. The most significant 
enlargement was seen in the submandibular region, 
where the largest nodule measured 2.3cm in diameter. 
It was also noted that there were retrocrural lymph 
nodes, particularly on the left side. Additionally, it was 
discovered that the internal and pericardial mammary 
chains had lymphadenopathy. Interestingly, the 
intralobular septations in the lungs showed a noticeable 

Figure 3: Ultrasound Upper Abdomen

Figure 4: Chest X-Ray



Pa
ge

 
18

8

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 2(2) 185-191, 2023

thickening, which suggested lymphangitis carcinomatosis. 
Small pulmonary nodules were also present, which were 
most obvious in the midzone of  the right lung. In both 
axillary regions, there was also significant lymph node 
enlargement, with some lymph nodes growing as large 
as 4 cm.
The CT scan of  the abdomen and pelvis revealed 
important liver-related findings. Figure 7 illustrates 
these findings, which included liver enlargement and 
the presence of  a nodular echo pattern, which was most 
obvious in the left lobe. The portal vein remained open, 

which was significant because it showed continuous blood 
flow. The intrahepatic bile ducts and liver vasculature also 
looked normal, and the portal vein’s diameter and patency 
were within normal limits. There were no clearly visible 
gallstones inside the gall bladder, which had a typical size, 
shape, and contour. There were no notable abnormalities 
in the liver’s surrounding region. The common bile ducts 
maintain a normal diameter and patency. Hepatic Segment 
Inferior Vena Cava demonstrates a typical diameter 
with unobstructed hepatic vein patency. Additionally, 
the spleen is notably enlarged, measuring 22cm. Lastly, 

Figure 5: Neck Ultrasound Report

Figure 6: CT Chest/Thorax (Without and With Contrast)



Pa
ge

 
18

9

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 2(2) 185-191, 2023

significant lymphadenopathy was observed at the iliac 
chains, resulting in compression of  the bladder.
The images show significantly enlarged lymphadenopathy 
in the neck, abdomen, pelvis, axillary, and inguinal regions, 
among other body parts. Hepatosplenomegaly was also 
seen, which points to lymphoma. Excisional lymph 
node biopsy was highly advised in order to confirm the 
diagnosis and carry out a thorough assessment. 
The case was discussed with a haemato-oncologist at 
Tawam Hospital, a tertiary hospital in the Emirate of  
Abu Dhabi. The haemato-oncologist recommended 
performing a lymph node biopsy to definitively 
confirm the diagnosis, a crucial step for acceptance 
into their department. Simultaneously, the patient was 
advised to initiate treatment with dexamethasone and 
allopurinol, medications that were prescribed to manage 
the condition. Following the referral for a lymph node 
biopsy, the patient was initially scheduled to undergo the 
procedure at the facility hospital; however, the patient 
did not attend. Subsequently, the patient sought care 
at Tawam Hospital. There, the lymph node biopsy was 
successfully performed on July 12th 2023, and the results 
confirmed the final diagnosis of  Follicular Lymphoma, 
specifically Grade 1A. Notably, circulating lymphoma 
cells were detected in the patient’s peripheral blood. 
Fortunately, the absence of  B symptoms in the clinical 
presentation indicated a relatively less aggressive form of  
the disease. This multidisciplinary approach underscores 
the importance of  accurate diagnosis and the immediate 
initiation of  appropriate treatment in managing the 
patient’s medical condition. These findings were pivotal 
for guiding the subsequent management and treatment 
plan for the patient’s condition.

In the tertiary hospital, a thorough workup was conducted 
for the patient diagnosed with FL to precisely determine 
the extent of  the disease and devise an optimal treatment 
approach. This evaluation included a thorough physical 
examination with an emphasis on the size of  the liver, 
spleen, and areas that contained lymph nodes. The clinical 
performance status and the presence of  B symptoms 
were evaluated to assess general health and symptomatic 
presentation. A full metabolic panel was used in the 
laboratory tests to assess metabolic parameters, as well 
as a complete blood count with differential and LDH 
measurements to track blood cell levels and disease 
activity. 
A treatment plan of  bendamustine and rituximab/
obintuzumab was discussed with the patient. This 
will be followed by maintenance therapy with 
rituximab or obintuzumab. An alternative of  CHOP-R 
(cyclophosphamide, doxorubicin, vincristine, prednisone 
plus rituximab) chemotherapy followed by rituximab 
maintenance was also recommended, if  the patient’s 
disease is limited to follicular lymphoma. Due to the 
patient’s age and fertility concerns with chemotherapy, 
fertility issues were discussed in detail. The patient 
was counselled on the potential risks to fertility from 
chemotherapy and the recommendation was made for 
him to pursue sperm banking prior to starting treatment. 

Figure 7: CT Abdomen and Pelvis (Without and With Contrast)

Figure 8: Final Diagnosis



Pa
ge

 
19

0

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 2(2) 185-191, 2023

All treatment options, potential side effects, risks and 
benefits were properly explained to the patient and an 
informed consent was obtained. 
A high-quality PET-CT scan was essential in identifying 
nodal and extranodal disease involvement during imaging 
studies. To assess cytopenias and record the disease 
stage, a bone marrow biopsy and aspirate were carried 
out. The patient had stage 4 FLIPI risk 4 and a Grade 1a 
FL, with an estimated 10-year survival rate of  35% and 
a leukemic phase. The importance of  a multidisciplinary 
approach to FL management is highlighted by the fact 
that this thorough workup served as the basis for creating 
a treatment plan that took into account the disease stage, 
risk factors, and the patient’s general health and fertility-
related needs.

DISCUSSION 
FL is characterised by its indolent nature, slow progression, 
and favourable outcomes, with an annual incidence of  
approximately 3.18 cases per 100,000 individuals. This 
incidence, while stable over time, exhibits variations 
with ethnicity, with the highest occurrence among white 
individuals. Fl accounts for a significant portion of  non-
Hodgkins lymphoma cases. 
FL typically presents in older individuals, with a median 
age of  >60 years at diagnosis (Freedman, 2018; Freedman 
& Jacobsen, 2020). However, our patient’s relatively young 
age at presentation highlights that FL can occur in younger 
adults, although it remains less common in this age group. 
This observation aligns with the rarity of  FL in pediatric 
and adolescent populations. FL presents insidiously 
with lymphadenopathy, often involving cervical, axillary, 
or inguinal lymph nodes. Patients may also experience 
systemic symptoms such as fever, night sweats and 
unintentional weight loss, referred to as B symptoms 
(Alnoor, Gandhi, Stein, & Gradowski, 2020; Dada, 2019). 
The diagnosis of  FL relies on histological examination 
of  a biopsy to assess grade and transformation potential 
accurately(Dada, 2019). Immunohistochemical staining is 
essential for confirming FL, with characteristic markers 
CD19, CD 20, CD10 monoclonal immunoglobulin and 
cytoplasmic expression of  bcl-2 protein (Agostinelli et al., 
2019; Alnoor et al., 2020).  A case report by Tomohiko 
Tanigawa et al. (2019) illustrates the occurrence of  
histological transformation from Grade 1 FL to Diffuse 
large B cell Lymphoma. Despite initial observation, 
the FL eventually transformed, leading to widespread 
involvement and resistance to standard chemotherapy 
(Tanigawa et al., 2019).  In another case study by Sarah 
Péricart et al. (2019), a 65-year-old man presented with 
a large abdominal mass and lymphadenopathy, raising 
suspicion of  lymphoma(Péricart et al., 2020). Biopsy 
revealed large tumour cells expressing histiocytic 
markers but lacking lymphoid markers. The diagnosis 
was histiocytic sarcoma (HS). Due to clinical and 
histological discordance, further lymph node biopsy was 
performed to confirm the diagnosis(Péricart et al., 2020). 
The literature revealed that both FL and HS tumours 

exhibited the t(14,18) translocation and shared clonal 
rearrangement, suggesting a clonal relationship between 
the two malignancies (Péricart et al., 2020). Furthermore, 
the patient’s leukocytosis with mature lymphocytes and 
smudged cells on the peripheral smear is consistent 
with haematological abnormalities often observed in 
lymphomas(Chabot‐Richards & George, 2014). This 
reinforces the significance of  haematological assessments 
in the diagnostic workup of  lymphoma patients.
The treatment approach for FL depends significantly 
on the disease stage at the time of  diagnosis (Lu, 2005). 
Patients with stage I disease, where the lymphoma is 
localised to one lymph node region or organ, often 
undergo radiation therapy (Los-de Vries et al., 2022). In 
contrast, patients diagnosed with stage III or IV disease, 
collectively termed “advanced stage,” are not typically 
curable with conventional therapies(Attarbaschi et al., 
2020). Instead, the focus shifts towards managing FL 
as a chronic condition with an emphasis on symptom 
control and improving the patient’s quality of  life(Lu, 
2005). Many individuals with stage III or IV FL receive 
a combination of  various treatment modalities over 
time, including immunotherapy, chemoimmunotherapy, 
and radiation therapy, often administered in different 
sequences with periods of  active therapy followed by 
observation and surveillance(Attarbaschi et al., 2020; Los-
de Vries et al., 2022). 
Ultimately, the choice of  treatment is tailored to the 
individual patient’s specific clinical presentation and needs, 
with the goal of  optimising outcomes and minimising the 
impact of  FL on their daily life.

CONCLUSION
The case reports underscore the significance of  early 
diagnosis, thorough evaluation, and a multidisciplinary 
approach in managing FL Grade 1A. Despite its indolent 
nature, FL can manifest in individuals of  varying ages. 
The absence of  B symptoms indicated a relatively less 
aggressive form of  FL, offering a more favourable 
prognosis. This case emphasises the importance of  
tailored treatment strategies to optimise outcomes in FL 
and highlights the ongoing need for research and clinical 
experience to enhance FL management.

LIMITATIONS
The report can not be generalised as it focuses on a single 
case. Another limitation of  the case is the missing long-
term follow-up and management of  the case, which could 
have given more information about the case.
 
REFERENCES
Agostinelli, C., Akarca, A. U., Ramsay, A., Rizvi, H., 

Rodriguez-Justo, M., Pomplun, S., . . . Daw, S. (2019). 
Novel markers in pediatric-type follicular lymphoma. 
Virchows Archiv, 475, 771-779. 

Alnoor, F., Gandhi, J. S., Stein, M. K., & Gradowski, J. F. 
(2020). Follicular Lymphoma Diagnosed in Warthin 
Tumor: A Case Report and Review of  the Literature. 



Pa
ge

 
19

1

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 2(2) 185-191, 2023

Head and Neck Pathology, 14(2), 386-391. doi:10.1007/
s12105-019-01045-x

Attarbaschi, A., Abla, O., Arias Padilla, L., Beishuizen, A., 
Burke, G. A., Brugières, L., . . . Klapper, W. (2020). 
Rare non‐Hodgkin lymphoma of  childhood and 
adolescence: a consensus diagnostic and therapeutic 
approach to pediatric‐type follicular lymphoma, 
marginal zone lymphoma, and nonanaplastic 
peripheral T‐cell lymphoma. Pediatric Blood & Cancer, 
67(8), e28416. 

Batlevi, C. L., Sha, F., Alperovich, A., Ni, A., Smith, K., 
Ying, Z., . . . Younes, A. (2020). Follicular lymphoma 
in the modern era: survival, treatment outcomes, and 
identification of  high-risk subgroups. Blood Cancer 
Journal, 10(7), 74. doi:10.1038/s41408-020-00340-z

Cahill, K. E., & Smith, S. M. (2022). Follicular 
Lymphoma: a Focus on Current and Emerging 
Therapies. Oncology (Williston Park), 36(2), 97-106. 
doi:10.46883/2022.25920946

Carbone, A., Roulland, S., Gloghini, A., Younes, A., von 
Keudell, G., López-Guillermo, A., & Fitzgibbon, J. 
(2019). Follicular lymphoma. Nature Reviews Disease 
Primers, 5(1), 83. doi:10.1038/s41572-019-0132-x

Chabot‐Richards, D., & George, T. (2014). Leukocytosis. 
International journal of  laboratory hematology, 36(3), 279-
288. 

Dada, R. (2019). Diagnosis and management of  follicular 
lymphoma: a comprehensive review. European journal 
of  haematology, 103(3), 152-163. 

Freedman, A. (2018). Follicular lymphoma: 2018 update 
on diagnosis and management. American Journal of  
Hematology, 93(2), 296-305. 

Freedman, A., & Jacobsen, E. (2020). Follicular lymphoma: 
2020 update on diagnosis and management. American 
Journal of  Hematology, 95(3), 316-327. 

Los-de Vries, G. T., Stevens, W. B., van Dijk, E., Langois-
Jacques, C., Clear, A. J., Stathi, P., . . . Sander, B. (2022). 
Genomic and microenvironmental landscape of  stage 
I follicular lymphoma, compared with stage III/IV. 
Blood Advances, 6(18), 5482-5493. 

Lu, P. (2005). Staging and Classification of  Lymphoma. 
Seminars in Nuclear Medicine, 35(3), 160-164. doi:https://
doi.org/10.1053/j.semnuclmed.2005.02.002

Péricart, S., Waysse, C., Siegfried, A., Struski, S., 
Delabesse, E., Laurent, C., & Evrard, S. (2020). 
Subsequent development of  histiocytic sarcoma 
and follicular lymphoma: cytogenetics and next-
generation sequencing analyses provide evidence 
for transdifferentiation of  early common lymphoid 
precursor—a case report and review of  literature. 
Virchows Archiv, 476(4), 609-614. doi:10.1007/s00428-
019-02691-w

Tanigawa, T., Abe, R., Kato, J., Hosoe, N., Ogata, H., 
Kameyama, K., . . . Mori, T. (2019). Histological 
transformation in duodenal-type follicular lymphoma: 
a case report and review of  the literature. Oncotarget, 
10(36), 3424.


