An 83-year-old man presented to our hospital with a 1-year history of progressive growth of an anal mass. The mass was infiltrating and elevated, its consistency was hard, and it was painless and pruritic. There was no history of fever, night sweats, abdominal pain, rectal bleeding, or constipation, although he reported a progressive weight loss of 5 kg. The patient had a medical history of diabetes mellitus. He had been diagnosed with pulmonary tuberculosis, correctly treated 40 years before, and nasal basocellular epithelioma, treated with radiation therapy 6 years before. Physical examination revealed cachexia and an indurated anal prolapse. Laboratory evaluation showed a hypoalbuminemia (27.3 g/liter) with hypergammaglobulinemia (IgG, 1,970 mg/dl [normal level, <1,600 mg/dl]; IgA, 574 mg/dl [normal level, <400 mg/dl]; and IgM, 93 mg/dl [normal level, <230 mg/dl]). The C-reactive protein level was 0.47 mg/liter, and the erythrocyte sedimentation rate was 99 mm/hour. The rheumatoid factor was 135 IU/ml (normal level, <30 IU/ml), and the anti-smooth muscle antibody test result was positive (1/80). The hemoglobin level was 11.5 g/dl, the platelet count was 217,000/μl, and the blood leukocyte count was 4,030/μl with 1,790 lymphocytes/μl. The CD4 T lymphocyte count was 539 cells/ml (30%), and the CD8 T lymphocyte count was 791 cells/ml (44%), with a T4/T8 lymphocyte ratio of 0.68. The HIV serology result was negative. Abdominal computed tomography showed no splenomegaly or lymphadenopathy and a normal liver. The colonoscopy result was normal except for a mucosal flat lesion on the proximal ascending colon, of which histology showed a tubular adenoma, and results for tumor markers were negative. A rectal biopsy was performed. Histopathological study of the anal mucosa disclosed an intense lymphoplasmacytic infiltrate in the dermis, with numerous macrophages, which contained basophilic point-like inclusions in the cytoplasm (Fig. 1).
FIG 1.
Hematoxylin and eosin-stained anal mucosa specimen showing an intense lymphoplasmacytic infiltrate in dermis with numerous macrophages, which contained basophilic point-like inclusions in the cytoplasm (original magnification ×200 and ×1,000, respectively).
(For answer and discussion, see page 1935–1936 in this issue [doi:10.1128/JCM.01530-14].)