DIFFUSE LARGE B-CELL LYMPHOMA PRESENTING AS DIFFUSE BILATERAL INNUMERABLE PULMONARY NODULES

Abstract

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) may rarely manifest as a primary pulmonary lymphoma or with secondary lung involvement. Typical radiologic presentations include chronic, indolent airspace consolidations, focal lung masses or perilymphatic lung nodules.(1) The objective of this report is to present rare secondary pulmonary involvement of DLBCL presenting as bilateral diffuse innumerable pulmonary nodules on chest computed tomographic (CT) imaging. This radiologic presentation has only previously been seen in the setting of acquired immunodeficiency syndrome (AIDS).(2) CASE PRESENTATION: A 67-year-old Caucasian woman with a history of stage IV DLBCL associated with a chest wall mass presented to the emergency department with chest pain and progressively worsening shortness of breath. Increasing oxygen requirements from baseline of 2L to 4L via nasal cannula, to maintain a pulse oximetry reading of 95% was noted. Physical examination was unremarkable with clear lung fields.Serology revealed bi-cytopenia, hemoglobin 11.0g/dL (normal 11.5-15.5g/dL) and platelets 81 k/uL (normal 150-400k/uL). LDH and CRP were elevated at 527U/L (normal 135-214U/L) and 6.4mg/dL (normal <0.9mg/dL) respectively. CT-chest with contrast showed no evidence of pulmonary embolism. However, innumerable bilateral diffuse lung nodules were noted (Figure 1). The left lower chest wall mass had increased in size. Broncho-alveolar lavage was negative for viral, bacterial and fungal etiologies. HIV serology, acid fast bacillus culture and stain were also negative. Transbronchial needle aspirate of enlarged lymph nodes was positive for lymphoma. Left lower lobe trans-bronchial biopsy revealed mild non-specific interstitial fibrosis but no granulomatous inflammation, neoplasm, or evidence of acute infection. Due to high suspicion of progression of her DLBCL as the underlying cause of her lung nodules, CT-guided biopsy of the lung nodules in the left lower lobe was performed. Diffuse sheets of large, CD5, 10 and 20 positive transformed lymphocytes were seen. Her diffuse bilateral innumerable pulmonary nodules were proven to be due to progression of her DLBCL disease. She received chemotherapy with bendamustine and rituximab. Her chest pain and oxygen requirements returned to her baseline, and she was discharged home one week later. DISCUSSION: This was a case of a 67-year-old Caucasian woman with stage IV DLBCL and secondary pulmonary involvement. Typical radiologic presentation of DLBCL with secondary pulmonary involvement is with a focal lung mass or perilymphatic lung nodules.(2) However, this patient presented with extensive bilateral diffuse innumerable pulmonary nodules unlike previous radiologic presentations of DLBCL described in immunocompetent patients. CONCLUSIONS: We suspect her pulmonary involvement was due to lymphatic spread of her DLBCL which may rarely occur in the setting of generalized disease.(3) REFERENCE #1: Lewis E, Caskey C, Fishman E. Lymphoma of the lung: CT Findings in 31 patients. AJR Am J Roentgenol. 1991 Apr;156(4):711-4. REFERENCE #2: Harbor N. Rapidly progressive diffuse large B-cell lymphoma presenting as innumerable pulmonary nodules in an Aids patient: A fatal case report. Journal of Hospital Medicine. 2015 March;abstract 604(10)supply 2. REFERENCE #3: Cheng C, Su Y, Chao T et al. Intralymphatic spread is a rare finding associated with poor prognosis in diffuse large B-cell lymphoma with extranodal involvements. Am J Surg Pathol. 2018 May;42(5):616-624. DISCLOSURES: No relevant relationships by Tanya Marshall, source=Web Response No relevant relationships by Atul Mehta, source=Web Response No relevant relationships by Prince Ntiamoah, source=Web Response No relevant relationships by Joseph Parambil, source=Web Response