Uncommon Diagnosis: Pulmonary B Cell Lymphoma Presenting as Non-Resolving Pneumonia

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Lung Pathology II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Persistent symptomatology or incomplete resolution of pneumonia despite treatment is a common clinical problem. Up to 20 percent of nonresponding community-acquired pneumonia may be due to noninfectious causes. Delay in diagnosis may lead to progression of disease and unnecessary antibiotics. We describe a case of diffuse large B cell lymphoma presenting as a non-resolving pneumonia. CASE PRESENTATION: A 62 year old man with a remote smoking history presented with 2 weeks of cough. A chest x-ray revealed lingular and left lower lobe opacities, and the patient was given Levaquin 750mg for 5 days. The patient initially showed clinical improvement but then presented with worsening of his cough. He was prescribed doxycycline 100mg bid for 10 days. A chest CT revealed extensive infiltrate in the left lower lobe with persistent symptoms despite treatment prompting hospitalization. Although he was afebrile with a WBC only mildly elevated at 11.8 K/UL, his ESR and CRP were significantly elevated at 94 mm/hr and 2.30 mg/dl, respectively. Sputum cultures grew normal oropharyngeal flora. A repeat chest CT scan after 10 days revealed extensive abnormalities in the left lower lobe with ground glass opacity in the Left upper lobe without pathologically enlarged lymph nodes (Image1). Due to the non-resolving nature of his symptoms and radiographic findings, the patient underwent bronchoscopy, which revealed marked mucosal abnormalities (Image 2). An endobronchial biopsy was obtained, which was positive for diffuse large B cell lymphoma. Pet scan shows hypermetabolism in the LLL, left infrahilar area and left hilum. He then consulted with his outside cancer institute for further management. DISCUSSION: Although non-resolving pneumonia is common, primary pulmonary lymphoma is rare. Less than 5 percent of non-Hodgkin lymphomas present with an alveolar infiltrate. Furthermore, it is often difficult to diagnose with standard fiberoptic bronchoscopy sampling techniques. However, given that resistant bacteria as well as less common infections such as, fungi, Nocardia, and Actinomyces are in the differential diagnosis, maintaining a broad differential and consideration of bronchoscopy is an important step in the approach to these patients, particularly since bronchoscopy is generally well-tolerated. CONCLUSIONS: Lack of at least partial radiographic resolution of pulmonary infiltrates by six weeks warrants consideration of alternative causes such as obstructing endobronchial lesions, resistant or atypical infection, or noninfectious causes. Reference #1: Lung India. 2013 Jan;30(1):27-32. doi: 10.4103/0970-2113.106130. A study on non-resolving pneumonia with special reference to role of fiberoptic bronchoscopy. Chaudhuri AD1, Mukherjee S, Nandi S, Bhuniya S, Tapadar SR, Saha M Reference #2: J Bronchology Interv Pulmonol. 2015 Oct 22. Pulmonary Parenchymal Lymphoma Diagnosed by Bronchoscopic Cryoprobe Lung Biopsy. Schiavo D1, Batzlaff C, Maldonado DISCLOSURE: The following authors have nothing to disclose: Zainab Mirza, Violet Kramer, Sharon Weiner No Product/Research Disclosure Information