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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

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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
DOI
10.1093/jjco/hyx194
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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 Oncology – Oxford University Press

Published: Mar 1, 2018

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