An unusual case of Lymphoma: Oropharynx like a Squamous Cell Carcinoma, Neck like Tuberculosis, Pathology of Epstein-Barr Virus until the Bitter End

Abstract

We report an unusual case of lymphoma that evaded histopathological diagnosis until the bitter terminal end. An elderly male patient, undergoing the latter stages of chemotherapy for myeloma, had been under our care as an outpatient for an ulcerative lesion of the right soft palate. Histopathological diagnosis of mucocutaneous Epstein-Barr Virus (EBV) had been made with ongoing symptomatic management. As a result of marked odynophagia and resultant poor nutrition, he was admitted for resuscitation and nutritional support. Further biopsies were performed and following the emergence of a palpable ipsilateral neck node, he underwent radiological and fine needle aspiration, which failed to substantiate a more sinister clinical suspicion. Further sampling suggested a possible tuberculosis infection, which was refuted on open biopsy. Eventually, after significant further clinical deterioration and tertiary-centre histopathological assessment, a diagnosis of EBV+ diffuse large B-cell lymphoma (DLBCL) was made. EBV+ DLBCL is a rapidly progressive variant that is thought to result from EBV-induced immune system modulation. It develops over the age of 50 (typically 70) and is slightly more common in men. It is also sometimes called “age- related EBV+ DLBCL”. Development of extra-nodal site EBV lesions in the above age group conveys a 70% incidence of EBV+ DLBCL, one such recognised site being the tonsil. Typically, however, it presents as lymphadenopathy. This case demonstrates the often-encountered high clinical suspicion that evades histopathological corroboration, until a late stage diagnosis is made, and a learning basis for lymphoproliferative disorders and their head and neck manifestations.