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CASE REPORT Table of Contents  
Ahead of print publication
Non-Hodgkin's lymphoma presenting with pulmonary involvement


1 Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Nuclear Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

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Date of Submission09-Sep-2020
Date of Acceptance25-May-2021
Date of Web Publication13-Jan-2022
 

  Abstract 


A 25-year-old woman presented with a history of episodes of fever with night sweats, multiple joint pains and breathlessness for 5 months. Eight months before the present episode, she had developed a generalised rash and transient swellings in the groin on both sides. Physical examination revealed pallor, pedal oedema and a hyperpigmented rash over the chest, back and thighs. Pulse was 126 beats per minute and respirations 38/min; while breathing ambient air, the oxygen saturation by pulse oximetry was 83%. On auscultation of the chest, breath sounds were diminished bilaterally and crepitations were heard in both the lung bases. Neurological examination revealed weakness of proximal muscles of both upper and lower limbs on both sides with a power of grade 3/5. Laboratory investigations revealed elevated total leucocyte count with neutrophilic leucocytosis; band forms and metamyelocytes were seen in the peripheral blood smear. Oxygen inhalation and broad-spectrum intravenous antibiotics were initiated. Echocardiogram showed severe tricuspid regurgitation with moderate pulmonary arterial hypertension. Computed tomography (CT) of the chest revealed patchy consolidation in both the lungs, bilateral pleural effusions and pericardial effusion. Bone marrow biopsy showed normocellular normoblastic marrow with erythroid hyperplasia. 18F-fluorodeoxyglucose positron emission tomography-CT showed metabolically active lymphadenopathy both above and below the diaphragm and bilateral patchy lung infiltrates. Biopsy of the inguinal lymph node along with immunohistochemistry staining confirmed the diagnosis as T-cell lymphoma.

Keywords: Diagnosis, diagnostic imaging, lung, lymphoma, non-Hodgkin, young adult


How to cite this URL:
Bhargav K M, Ramya M S, Mohan A, Rukmangada N, Kalawat T C, Sairam N, Kumar C S. Non-Hodgkin's lymphoma presenting with pulmonary involvement. J Clin Sci Res [Epub ahead of print] [cited 2022 Jul 4]. Available from: https://www.jcsr.co.in/preprintarticle.asp?id=335777





  Introduction Top


In 2018, globally 509,590 new cases and 248,724 deaths occurred due to non-Hodgkin's lymphoma (NHL); in India, there were 28,110 new cases and 23,510 deaths due to NHL.[1],[2] The most common type of NHL in India is B-cell lymphoma that accounts for 80%–85%; T-cell lymphoma accounts for 10%–15% of all NHLs in India.[3] Pulmonary involvement occurs uncommonly in patients with lymphoma and has been documented to occur in about 10% of patients with T-cell lymphomas; pulmonary involvement is associated with increased mortality in these patients.[4] We report the case of a patient with T-cell lymphoma who had pulmonary involvement.


  Case Report Top


A 25-year-old woman presented to our tertiary care teaching hospital with a history of fever episodes for 5 months, joint pains for 2 months and breathlessness for 3 days. Eight months before the presentation, she had developed a generalised rash and transient palpable swellings in the groin region on both sides. On general physical examination, pallor, bilateral pitting pedal oedema and a hyperpigmented rash involving the chest, back and thighs were noted; there was no clinically evident peripheral lymphadenopathy. Pulse was 126 beats per minute, respirations 38/Min and blood pressure 100/70 mmHg. While breathing ambient air, her oxygen saturation by pulse oximetry was 83%. Chest auscultation revealed that breath sounds were diminished in the right infrascapular area and absent in the infra-axillary area on both sides, and crepitations were noted in the infrascapular area on both sides. Neurological examination revealed proximal muscle weakness in both the upper and lower limbs with a power of 3/5 (Medical Research Council grading).

Laboratory investigations revealed elevated total leucocyte count (29,100 cells/mm3) with neutrophilic leucocytosis. Band forms and metamyelocytes were increased, constituting 3% and 1% of all leucocytes, respectively. The echocardiogram showed severe tricuspid regurgitation with moderate pulmonary arterial hypertension (PAH). Computed tomography (CT) of the chest revealed consolidation in both lungs, bilateral pleural effusion and pericardial effusion. A working diagnosis of non-resolving pneumonia of the right and left lobes was made. Pulmonary tuberculosis and lung abscess were considered as differential diagnosis.

She was admitted to the medical intensive care unit. Oxygen inhalation and intravenous broad-spectrum antibiotics were initiated. Sputum Xpert MTB/RIF testing was negative. As the patient did not improve clinically, a bone marrow biopsy was done as part of the diagnostic workup which showed a normocellular normoblastic marrow with erythroid hyperplasia. Ultrasonogram of the neck showed sub-centimetre cervical lymphadenopathy. 18F-fluorodeoxyglucose positron emission tomography-CT (18FDGPET-CT) scan showed metabolically active lymphadenopathy both above and below the diaphragm with bilateral metabolically active patchy lung infiltrates and a metabolically active splenomegaly [Figure 1]. A biopsy of the inguinal lymph node showed partially effaced lymph node architecture with replacement by atypical lymphoid cells, suggestive of lymphoma. Immunohistochemistry staining was positive for the T-cell marker CD3 [Figure 2] and negative for the B-cell markers CD19 and CD20 confirming the diagnosis of T-cell lymphoma. The patient was diagnosed to have Stage III NHL as per the Lugano classification (2014).[5] The patient was discharged with advice to attend medical oncology outpatient service for further management.
Figure 1: 18Flurodeoxyglucose PET-CT maximum intensity projection image (a); non-contrast CT axial image at the neck, thorax and abdomen (b-d) and corresponding PET-CT-fused images (e-g) showing increased FDG concentration in enlarged spleen, bilateral enlarged neck and abdominal nodes. Findings are also consistent with patches of ground-glass opacity with increased 18Flurodeoxyglucose concentration in both side lung parenchyma, suggestive of bilateral active infection. PET-CT = Positron emission tomography-computed tomography; CT = Computed tomography; FDG = Flurodeoxyglucose

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Figure 2: Photomicrograph showing effaced lymph node architecture with extensive vascular proliferation (Haematoxylin and eosin, ×40) (a); small-to-medium-sized cells with irregular nuclear contours, vesicular chromatin. Few scattered large cells with prominent nucleoli and clusters of histiocytes, mitotic figures (arrow) are also evident (Haematoxylin and eosin, ×400) (b); immunohistochemistry was positive for the T-cell marker CD3 (×400) (c)

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  Discussion Top


NHL has a median age at diagnosis in the sixth decade. Our case documents the uncommon occurrence of NHL at a relatively young age of 25 years. NHL usually presents as peripheral lymph node swellings, with common extra-nodal sites of involvement being the skin and gastrointestinal tract.[6] Our patient presented with respiratory tract involvement. In our patient, the initial diagnosis of non-resolving pneumonia was considered at the time of initial presentation due to fever, tachypnoea and evidence of bilateral consolidation on CT of the chest. Presentation of lymphomas with fever and respiratory symptoms that were due to primary or secondary involvement of the lungs by the lymphoma has seldom been documented. Literature review shows working up of non-resolving pneumonia leading to diagnosis of lymphoma in few case reports.[7] The chest CT findings in NHL can be varied and can present as peribronchial or perivascular thickening, mass or mass-like consolidation, nodules, pleural-based masses and mediastinal lymphadenopathy. The presence of air bronchograms, nodules <1 cm in size and pleural effusions are seen in lymphoma. Two-thirds of cases can have more than one abnormal lung finding, and there can be involvement of lung parenchyma at different sites. Such varied CT chest findings may help differentiate lymphoma from allergic or infectious processes in the lung.[8]

In the present case, PAH was observed on echocardiogram, increased 18FDG uptake was noted in the lungs and lymph node groups on both sides of the diaphragm and NHL was confirmed by lymph node biopsy. Another report[8] documents an elderly male who had diffuse ground-glass opacities and interlobular septal thickening on CT chest and PAH with increased 18FDG uptake on PET-CT in lymph node groups and lungs. He was finally diagnosed as a case of T-cell lymphoma with pulmonary involvement. The cause for PAH was attributed to the invasion of pulmonary vessels by the atypical lymphoid cells, which was a rare finding.[9] In these cases, diagnosis was established by means of PET-CT and lung biopsy.

Early diagnosis and management of lymphoma might change the clinical course. This case highlights the importance of a vigilant approach to a young patient presenting with a pneumonia-like clinical presentation with consolidation on CT chest.

Financial support and sponsorship

Nil.

Conflicts of interest

Alladi Mohan is an Editor of Journal of Clinical and Scientific Research. The other authors are faculty members/residents of Sri Venkateswara Institute of Medical sciences, Tirupati, of which Journal of Clinical and Scientific Research is the official Publication. The article was subject to the journal's standard procedures, with peer review handled independently of these faculty and their research groups.



 
  References Top

1.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.  Back to cited text no. 1
    
2.
Globocan 2018: India Factsheet. Available from: http://cancerindia.org.in/globocan-2018-india-factsheet/. [Last accessedon 2020 Sep 09].  Back to cited text no. 2
    
3.
Nair R, Arora N, Mallath MK. Epidemiology of non-Hodgkin's lymphoma in India. Oncology 2016;91 Suppl 1:18-25.  Back to cited text no. 3
    
4.
Fujisawa T, Suda T, Matsuura S, Enomoto N, Takeshita K, Ohnishi K, et al. Peripheral T-cell lymphoma with diffuse pulmonary infiltration and an increase in serum KL-6 level. Respirology 2007;12:452-4.  Back to cited text no. 4
    
5.
Cheson BD, Fisher RI, Barrington SF, Cavalli F, Schwartz LH, Zucca E, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: The Lugano classification. J Clin Oncol 2014;32:3059-68.  Back to cited text no. 5
    
6.
Newton R, Ferlay J, Beral V, Devesa SS. The epidemiology of non-Hodgkin's lymphoma: Comparison of nodal and extra-nodal sites. Int J Cancer 1997;72:923-30.  Back to cited text no. 6
    
7.
Qiu Y, Hou J, Hao D, Zhang D. Primary pulmonary NK/T-cell lymphoma: A case report and literature review. Mol Clin Oncol 2018;8:753-6.  Back to cited text no. 7
    
8.
Lewis ER, Caskey CI, Fishman EK. Lymphoma of the lung: CT findings in 31 patients. Am J Roentgenol 1991;156:711-4.  Back to cited text no. 8
    
9.
Watanabe S, Takato H, Waseda Y, Tokuda A, Katayama N, Kondo Y, et al. Pulmonary T-cell lymphoma with pulmonary arterial hypertension. Intern Med 2011;50:1733-6.  Back to cited text no. 9
    

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Correspondence Address:
KM Bhargav,
Assistant Professor, Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCSR.JCSR_82_20



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    -  Bhargav K M
    -  Ramya M S
    -  Mohan A
    -  Rukmangada N
    -  Kalawat T C
    -  Sairam N
    -  Kumar C S


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