NOT ALL CAVITARY LESIONS WITH AIR FLUID LEVELS ARE LUNG ABSCESSES

Abstract

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary Pulmonary Hodgkin lymphoma is very rare, less than 100 cases have been reported (1,2) as they comprise less than 0.5 % of lung neoplasias (3,4) and of out of those only 2% are PPHL (5). Diagnosis of this neoplasm is very challenging because it usually presents with nonspecific symptoms and radiological images that can be attributed to other etiologies such as infection. CASE PRESENTATION: 26-year-old male presented to his PCP with dry cough, fevers, chills, night sweats, 20-pound unintentional weight loss, and dyspnea for a month. Outpatient treatment with azithromycin for a presumed pneumonia failed and he was admitted to the hospital. He was found to be febrile (39c) and tachycardic (123 beats/min). Laboratory work up was notable for a WBC 25.9. Chest x-ray showed left upper lobe (LUL) lung abscess and left side effusion. He was started on broad spectrum antibiotics. Sputum gram stain was positive for MRSA. CT of the chest showed extensive cavitary necrotic airspace consolidation of the LUL and lingula with moderate left sided pleural effusion(Fig 1). Pleural fluid analysis was found to be exudative in nature. AFB samples were negative. BAL showed gram positive cocci in clusters, however, culture results were negative. Despite antibiotics, the fever persisted, and the patient underwent a second thoracentesis and CT scan that showed progression of the left sided cavitary lesion(2). Repeat bronchoscopy with transbronchial needle biopsy was negative for malignancy. The patient’s symptoms improved, and he was discharged home on antibiotics. One month later the patient was readmitted due to persistent progressive SOB and weight loss. Broad spectrum antibiotics were initiated and repeat BAL was unrevealing. Ultimately, the patient underwent FNA and multiple biopsies around the rim of the LUL “abscess” revealed classical Nodular Sclerosing Hodgkin lymphoma. The patient underwent one cycle of chemotherapy and his symptoms improved significantly, and he was discharged with outpatient follow up. Unfortunately a few months later he presented with the same symptoms and similar CT findings.(Fig 3) DISCUSSION: Cavitary lesions in the lung have a broad differential (6), it is important to consider different etiologies in a patient with recurrent symptoms and non-resolving radiographic abnormalities. Due to the nonspecific signs, symptoms, laboratorial and radiological findings of primary pulmonary lymphomas the diagnosis is very challenging and usually delayed (7, 8) Such as in our case the patient received multiple empirical broad-spectrum antibiotics for suspected abscess without complete resolution of symptoms and progression of radiographic findings. CONCLUSIONS: Our case highlights the importance of considering other differentials for cavitary lung lesions in the treatment plan especially when confronted with a non-resolving symptoms. Reference #1: Rodriguez J, Tirabosco R, Pizzolitto S, et al. Hodgkin lymphoma presenting with exclusive or preponderant pulmonary involvement: a clinicopathologic study of 5 new cases. Ann Diagnos Path 2006;10:83–8 Reference #2: Primary pulmonary Hodgkin's lymphoma and a review of the literature since 2006 Reference #3: Primary Pulmonary Involvement in Mucosa-associated Lymphoid Tissue Lymphoma DISCLOSURES: No relevant relationships by Karim Anis, source=Web Response No relevant relationships by Victor Zavala, source=Web Response