Atypical radiological presentation of pulmonary invasion of diffuse large B-cell lymphoma mimicking Pneumocystis jiroveci pneumonia

Atypical radiological presentation of pulmonary invasion of diffuse large B-cell lymphoma... A 66-year-old male was diagnosed with advanced-stage diffuse large B-cell lymphoma (DLBCL). At the time of initial diagnosis, the patient had nodular pulmonary invasion on computed tomography (CT) (Fig. 1A). He received eight cycles of cyclophosphamide, doxorubicin, vincristine and prednisolone in combination with rituximab (R-CHOP) therapy and achieved complete response. Figure 1. View largeDownload slide The patient had nodular pulmonary invasion on the CT scan at initial diagnosis of DLBCL (A). One year after the end of initial treatment, the patient presented with dyspnea and CT scan revealed diffuse ground glass opacity mimicking PCP (B). However, transbroncheal lung biopsy demonstrated the relapse of DLBCL (hematoxylin & eosin ×400 [C], CD20 ×200 [D]). Abbreviations: CT, computed tomography; DLBCL, diffuse large B-cell lymphoma; PCP Pneumocystis jiroveci pneumonia. Figure 1. View largeDownload slide The patient had nodular pulmonary invasion on the CT scan at initial diagnosis of DLBCL (A). One year after the end of initial treatment, the patient presented with dyspnea and CT scan revealed diffuse ground glass opacity mimicking PCP (B). However, transbroncheal lung biopsy demonstrated the relapse of DLBCL (hematoxylin & eosin ×400 [C], CD20 ×200 [D]). Abbreviations: CT, computed tomography; DLBCL, diffuse large B-cell lymphoma; PCP Pneumocystis jiroveci pneumonia. One year after completing R-CHOP therapy, he presented with dyspnea and fever up to 38°C. Arterial blood gas analysis in room air revealed hypoxia with a partial pressure of oxygen of 59.9 Torr and increase in the alveolar-arterial oxygen difference to 51.2 Torr. Chest CT revealed bilateral diffuse ground glass opacification predominantly involving perihilar and mid zones with peripheral sparing, which are typical of Pneumocystis jiroveci pneumonia (PCP) (Fig. 1B). Based on physical and radiological findings, he was clinically suspected of having PCP and trimethoprim-sulfamethoxazole and prednisolone at 1.0 mg/kg/day were started. However, his CD4 count in peripheral blood was higher than 400/μl, and the serum beta-d-glucan level was not elevated. The human immunodeficiency virus screening test was negative. There was no evidence of cytomegalovirus infection, collagen diseases, or hypersensitivity pneumonitis. Subsequently, he received bronchoscopy to make a definitive diagnosis; Pneumocystis jiroveci polymerase chain reaction of bronchoalveolar lavage fluid was negative and transbronchial lung biopsy revealed involvement of large atypical lymphocytes (Fig. 1C, hematoxylin & eosin, ×400), and these cells were positive for CD20 which is a specific surface marker of B-cell lymphomas (Fig. 1D, ×200). Based on these findings, the relapse of DLBCL was confirmed histologically. After that, the patient received salvage chemotherapy and pulmonary lesions disappeared. The ground glass opacities caused by DLBCL is rare CT findings. In most cases, the pulmonary invasion of lymphomas presents nodule or focal consolidations. This case suggests that: (1) bronchoscopy is useful to determine the etiology of ground glass opacity and (2) pulmonary invasion of lymphoma exhibits several radiological patterns, including nodular lesions and ground glass opacity mimicking PCP. As PCP is a potentially life-threatening infection, urgent therapy based on clinical diagnosis may be necessary. However, efforts should be made to obtain respiratory specimens to confirm the diagnosis at any time. Authors' contributions R.I.H. and D.M. are the attending physicians for this patient. R.I.H. and S.M. wrote the initial draft of the manuscript. A.M.M. contributed to pathological interpretation. The final version of the manuscript was approved by all authors. Conflict of interest statement We declare no competing interests. © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Japanese Journal of Clinical Oncology Oxford University Press

Atypical radiological presentation of pulmonary invasion of diffuse large B-cell lymphoma mimicking Pneumocystis jiroveci pneumonia

Loading next page...
 
/lp/ou_press/atypical-radiological-presentation-of-pulmonary-invasion-of-diffuse-TPxqZoYZqm
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
ISSN
0368-2811
eISSN
1465-3621
D.O.I.
10.1093/jjco/hyx194
Publisher site
See Article on Publisher Site

Abstract

A 66-year-old male was diagnosed with advanced-stage diffuse large B-cell lymphoma (DLBCL). At the time of initial diagnosis, the patient had nodular pulmonary invasion on computed tomography (CT) (Fig. 1A). He received eight cycles of cyclophosphamide, doxorubicin, vincristine and prednisolone in combination with rituximab (R-CHOP) therapy and achieved complete response. Figure 1. View largeDownload slide The patient had nodular pulmonary invasion on the CT scan at initial diagnosis of DLBCL (A). One year after the end of initial treatment, the patient presented with dyspnea and CT scan revealed diffuse ground glass opacity mimicking PCP (B). However, transbroncheal lung biopsy demonstrated the relapse of DLBCL (hematoxylin & eosin ×400 [C], CD20 ×200 [D]). Abbreviations: CT, computed tomography; DLBCL, diffuse large B-cell lymphoma; PCP Pneumocystis jiroveci pneumonia. Figure 1. View largeDownload slide The patient had nodular pulmonary invasion on the CT scan at initial diagnosis of DLBCL (A). One year after the end of initial treatment, the patient presented with dyspnea and CT scan revealed diffuse ground glass opacity mimicking PCP (B). However, transbroncheal lung biopsy demonstrated the relapse of DLBCL (hematoxylin & eosin ×400 [C], CD20 ×200 [D]). Abbreviations: CT, computed tomography; DLBCL, diffuse large B-cell lymphoma; PCP Pneumocystis jiroveci pneumonia. One year after completing R-CHOP therapy, he presented with dyspnea and fever up to 38°C. Arterial blood gas analysis in room air revealed hypoxia with a partial pressure of oxygen of 59.9 Torr and increase in the alveolar-arterial oxygen difference to 51.2 Torr. Chest CT revealed bilateral diffuse ground glass opacification predominantly involving perihilar and mid zones with peripheral sparing, which are typical of Pneumocystis jiroveci pneumonia (PCP) (Fig. 1B). Based on physical and radiological findings, he was clinically suspected of having PCP and trimethoprim-sulfamethoxazole and prednisolone at 1.0 mg/kg/day were started. However, his CD4 count in peripheral blood was higher than 400/μl, and the serum beta-d-glucan level was not elevated. The human immunodeficiency virus screening test was negative. There was no evidence of cytomegalovirus infection, collagen diseases, or hypersensitivity pneumonitis. Subsequently, he received bronchoscopy to make a definitive diagnosis; Pneumocystis jiroveci polymerase chain reaction of bronchoalveolar lavage fluid was negative and transbronchial lung biopsy revealed involvement of large atypical lymphocytes (Fig. 1C, hematoxylin & eosin, ×400), and these cells were positive for CD20 which is a specific surface marker of B-cell lymphomas (Fig. 1D, ×200). Based on these findings, the relapse of DLBCL was confirmed histologically. After that, the patient received salvage chemotherapy and pulmonary lesions disappeared. The ground glass opacities caused by DLBCL is rare CT findings. In most cases, the pulmonary invasion of lymphomas presents nodule or focal consolidations. This case suggests that: (1) bronchoscopy is useful to determine the etiology of ground glass opacity and (2) pulmonary invasion of lymphoma exhibits several radiological patterns, including nodular lesions and ground glass opacity mimicking PCP. As PCP is a potentially life-threatening infection, urgent therapy based on clinical diagnosis may be necessary. However, efforts should be made to obtain respiratory specimens to confirm the diagnosis at any time. Authors' contributions R.I.H. and D.M. are the attending physicians for this patient. R.I.H. and S.M. wrote the initial draft of the manuscript. A.M.M. contributed to pathological interpretation. The final version of the manuscript was approved by all authors. Conflict of interest statement We declare no competing interests. © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Journal

Japanese Journal of Clinical OncologyOxford University Press

Published: Mar 1, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 12 million articles from more than
10,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Unlimited reading

Read as many articles as you need. Full articles with original layout, charts and figures. Read online, from anywhere.

Stay up to date

Keep up with your field with Personalized Recommendations and Follow Journals to get automatic updates.

Organize your research

It’s easy to organize your research with our built-in tools.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

Monthly Plan

  • Read unlimited articles
  • Personalized recommendations
  • No expiration
  • Print 20 pages per month
  • 20% off on PDF purchases
  • Organize your research
  • Get updates on your journals and topic searches

$49/month

Start Free Trial

14-day Free Trial

Best Deal — 39% off

Annual Plan

  • All the features of the Professional Plan, but for 39% off!
  • Billed annually
  • No expiration
  • For the normal price of 10 articles elsewhere, you get one full year of unlimited access to articles.

$588

$360/year

billed annually
Start Free Trial

14-day Free Trial