Pyothorax-associated lymphoma in an elderly woman with a history of lung tuberculosis.

Abstract

To the Editor: An 81-year-old woman was admitted to our acute geriatric ward because of recent delirium and fever. Eight days before admission, she had fallen at home, and two right rib fractures were discovered. In the previous 2 months, she had been complaining of asthenia, anorexia, and weight loss. Simultaneously, a severe functional decline was observed. The patient reported no chest pain. The medical history of the patient consisted of right lung tuberculosis at age 30, treated with artificial pneumothorax, and mild Alzheimer's disease diagnosed 2 years before hospitalization. On presentation to the hospital, the patient had a fever of 39°C and macroscopic pyuria. Other than right diffuse expiratory wheezing and severe denutrition, the physical examination was unremarkable. Investigations revealed a total white blood cell count of 17 × 109/L, a C-reactive protein level of 110 mg/L, and thrombocytosis of 700 × 109/L, suggestive of sepsis. The lactic dehydrogenase level was 1,095 IU/L and a monoclonal gammopathy (immunoglobulin G Lambda) was found using serum protein electrophoresis. Urine culture was positive with Escherichia coli. Chest x-ray showed three right anterior rib fractures, a round and well-limited opacity of the superior lobe of the right lung, and signs of pleuritis. There was no change from an x-ray 2 years before, and it was considered to be chronic pyothorax after right lung tuberculosis. The patient was started on antibiotic treatment but remained febrile despite her urine becoming sterile. Sputum specimens were negative for Myobacterium tuberculosis. Chondrocalcinosis of the left wrist was detected a few days later and treated with colchicine with good local results, but the inflammatory syndrome, the leukocytosis, and the fever remained unchanged. Finally, the patient underwent thoracic and abdominal computed tomography (CT) and thoracic magnetic resonance imaging (MRI, Figure 1), which showed a liquid cavity of the superior lobe of the right lung with calcifications. The posterior wall of this cavity was invaded by an irregular tumor expanding to the right ribs and to the thoracic vertebrae and epidural space between T5 and T9. No adenopathy was found. Abdominal organs were normal, and no lung cancer was found. A CT-guided biopsy of the tumor was performed and showed diffuse large B-cell lymphoma. Because of the poor condition of the patient, no chemotherapy was possible, and she was started on oral prednisolone. She was also treated with radiotherapy to avoid compression of the thoracic spinal cord by the tumor (10 gray (radiation unit 1) in two short sessions). Nevertheless, the patient's condition worsened, and she died few days later with sudden respiratory distress suggesting severe pulmonary embolism. Pyothorax-associated lymphoma (PAL) is a rare but distinct clinicopathologic entity that occurs most often in Japanese people, particularly in elderly patients. PAL develops in the pleural cavity of patients affected by long-standing pyothorax resulting from pulmonary tuberculosis treated with artificial pneumothorax.1 The tumor develops several decades after the pneumothorax and may progress as a type of extranodal lymphoma.2 PAL is also known to be associated with Epstein-Barr virus infection.3 The most common symptoms are chest and back pain, asthenia, and fever. It is often difficult to detect the tumor mass using chest x-ray because of old inflammatory changes. CT scan or MRI is useful in making the diagnosis. PAL is responsive to chemotherapy (cyclophosphamide, adriamycin, vincristine, and prednisolone),1 and local radiotherapy treatment (50 gray with wide margins) is also recommended to treat PAL.4 Nevertheless, the overall prognosis remains poor.5 However, PAL is a rare hematological malignancy, and awareness should be raised in geriatricians that elderly patients with a history of tuberculous pyothorax should be followed up carefully. Magnetic resonance image scan of the pyothorax-associated lymphoma tumor.