Diffuse Large B-cell Lymphoma Presenting as Cavitary Lung Disease and Massive Hemoptysis

Abstract

Introduction: The differential diagnosis of cavitary lung disease and hemoptysis are broad but mostly occurs from infections (pneumonia, tuberculosis, fungal infections) and malignancies. Primary lung cancers, particularly with squamous cell histology are the most common cause of cavitary lung lesion and hemoptysis. We present a case of a Diffuse Large B-cell Lymphoma (DLBCL) in a patient who presented with cavitary lung disease and massive hemoptysis. Case: A 49-year-old male with history of smoking (30 pack years) and coronary artery disease presented to the emergency department with shortness of breath, tachycardia and hemoptysis. He also endorses a 15lb weight loss, and night sweats over past 3 months. On exam he was afebrile, tachycardic with normal blood pressure and oxygen saturation 84% on room air, requiring 4 L/min of supplemental oxygen to increase oxygen saturation above 89%. Bronchial breath sounds were heard on the right side on chest exam. Lab showed normal WBC count, hemoglobin of 10.5 gm/dl and Sodium of 128 mmol/L. COVID-19 negative, AFB negative x3, HIV negative, sputum culture negative. The patient was empirically treated with broad spectrum antibiotics. CT chest showed right upper lobe cavitation which extended to the lower lobe as well. Bronchoscopy with right upper lobe lavage, brushings, endobronchial biopsy and transbronchial biopsy were done. While awaiting the biopsy results the patient was transferred to ICU for close monitoring and thoracic surgery and interventional radiology were consulted. Unfortunately, the patient had massive hemoptysis leading to cardiopulmonary arrest and death. The bronchoscopic histopathology returned as DLBCL. Autopsy report of the right lung tumor was consistent with large B-cell lymphoma measuring approximately 14 x 11cm with extensive necrosis. Discussion: About 20% of the patients with cancer present with hemoptysis. While some present with blood tinged sputum, others present with massive hemoptysis (which is defined as 100-400 ml in 24 hours). Primary lung cancer is the most common cause of cavitary lung disease and hemoptysis, particularly squamous cell cancer. Diffuse Large B-cell lymphoma rarely causes cavitary lung disease and hemoptysis. It is difficult to radiologically differentiate lymphoma from infection, primary lung cancer, or granulomatosis with polyangiitis. It is important to consider lymphoma in the differential diagnosis and to consider early diagnostic and therapeutic intervention when cavitary lung disease with massive hemoptysis is observed.