Dysurian as first Presentation of Bladder Lymphoma

A 5-year old boy presented with dysuria and bright red colored urine two days ago. Physical exam was remarkable for sever cachexia, and suprapubic tenderness. In primary study BUN and creatinin were normal but urine analysis had puyria and RBC, renal sonogram reported increment of bladder thickness. With suspicious to cystitis antibiotic was started, subsequently symptoms relieved. Two weeks later, he cam with hematuria and abdominal pain. A mass in supra pubic area was palpable. Foley catheter was inserted and the small amount of urine was drained. Repeated renal scan confirmed a bladder thickness of 28 mm with bilateral hydronephrosis. BUN and creatinin elevated and uric acid level was 23. Patient became oliguric. Abdominal CT scan without contrast revealed bladder thickness and bilateral hydronephrosis predominantly in left side ( figure one) . with diagnosis of post renal acute kidney injury cystoscopy was done . Left uretero vesico junction was completely obstructed and the attempts for setting JJ in two side was unsuccessful and just biopsy was done. Tube nephrostomy helped to drain urine and creatinin decreased. Bone marrow aspiration and bladder biopsy( figure two) were in favor of leukemic lymphoma. Bone marrow replacement by large lymphoblast with prominent cytoplasmic vacuolation (Burkitt lymphoma/ ALL L3). Immunophenotype was increased (CD10, CD20, CD45, and HLA-DR). and SIgM was also increased. Standard protocol of chemotherapy was started (LMB89).