INTRODUCTION: Primary pulmonary lymphoma is a rare disease. It accounts for 0.5-1% of all pulmonary malignancy and less than 1 % of all Non-Hodgkins Lymphoma (NHL) (1). Mostly they are of B cell origin; however, there are fourteen reported primary pulmonary peripheral T Cell Lymphoma cases (2). We report a case of a patient presenting with primary pulmonary peripheral T cell Lymphoma. CASE PRESENTATION:A 58-year-old woman presented with complaints of dyspnea, high-grade fever, and cough for the past 4-5 days. Physical exam was unremarkable except for the fever, tachycardia, tachypnea, and oxygen saturation of 87% on room air. Laboratory workup was unremarkable except for elevated ESR, CRP, LDH, and ferritin. Rheumatological workup was unremarkable. Infectious workup, including COVID-19 PCR, blood cultures, and respiratory viral panel, were unremarkable. Chest CT showed bilateral consolidation of lungs with hilar and mediastinal lymphadenopathy (fig 1). She was started on broad-spectrum antibiotics and admitted to the medical floor. Her dyspnea got progressively worse, and she was intubated a week after her admission. Bronchoscopy was done with bronchoalveolar lavage and transbronchial biopsy; however, results were unremarkable. Video-assisted thoracoscopic surgery ( VATS ) was done for mediastinal lymph node biopsy, and biopsy results came positive for peripheral T cell lymphoma(Fig 2 , 3 ). Bone marrow biopsy was unremarkable. The patient started to desaturate even on the maximal ventilator setting and was placed on venovenous extracorporeal membrane oxygenation (V-V ECMO). She was given the first cycle of Gemcitabine and oxaliplatin. However, she developed multiorgan failure. She was transitioned to comfort care and expired.DISCUSSION: Primary pulmonary peripheral T cell lymphoma usually manifests with the symptoms of dyspnea, cough, and fever. The mean age of presentation is fifty-three years. Radiographically it presents with lung consolidation, atelectasis, pleural effusion, and multiple nodular lesions. (3) Our patient had bilateral lung consolidation with hilar and mediastinal lymphadenopathy. Diagnosis is made by lobectomy, open lung biopsy, transthoracic needle biopsy, and mediastinal lymph node biopsy. (3) There is still no recommended standard treatment for primary pulmonary T cell lymphoma due to the scarcity of cases (4). Resection, radiotherapy, and chemotherapy are the treatment options used in patients suffering from this disease.CONCLUSIONS: Primary pulmonary peripheral T cell lymphoma is a rare and aggressive cancer. It presents with pneumonialike symptoms. We recommend clinicians to consider bronchoscopy for those patients with pneumonia who do not get better with antibiotics.
INTRODUCTION: Dyspnea and wheezing are the common complaints encountered in the primary care setting. Primary care physicians should keep the common diseases in their minds while also keeping the rare diseases in their differential diagnosis. The incidence of pulmonary carcinoid is around 5 cases/100,000. Carcinoid tumors comprise 2% of all lung tumors. (1) Hemoptysis and cough are the most common symptoms associated with pulmonary carcinoid. We report a case of a patient who presented with refractory wheezing. CASE PRESENTATION:A 36-year-old lady with a history of asthma presented with worsening dyspnea and wheezing for the past one month. She had no other complaints. She was frequently using an albuterol inhaler; however, she had no benefit. Physical examination was unremarkable except for wheezing. She was prescribed a corticosteroid and salmeterol inhaler. She denied resolution of wheezing and dyspnea despite using inhalers for one month. On her follow-up visit, CXR was performed, which was remarkable for the left lower lobe lung mass. CT Chest showed 4x5 cm mass in the left lower lobe of the lung (fig 1). PET CT scan was significant for Gallium-68 dotatate uptake in the left lung lower lobe evident for somatostatin-rich carcinoid tumor (fig 2). 24h urinary 5-hydroxyindoleacetic Acid (5-HIAA) was unremarkable. Bronchoscopy demonstrated a large occlusive left lower lobe mass. The bronchial biopsy was remarkable for typical carcinoid. She underwent left lower lobectomy with mediastinal lymph node dissection. Lung biopsy showed low-grade typical carcinoid (fig 3). Mediastinal lymph nodes were negative for any metastasis. She had an uneventful stay at the hospital and was discharged. She had a resolution of wheezing and dyspnea at a follow-up visit.DISCUSSION: Pulmonary carcinoid is a rare disease. Typical carcinoids are more prevalent than atypical carcinoids. Typical carcinoids are low-grade tumors, while atypical carcinoids are high-grade tumors (2). We hypothesize that our patient had wheezing, and dyspnea due to the mass effect of carcinoid tumor. Centrally located tumors present with hemoptysis, cough, and recurrent respiratory tract infections while peripherally located tumors are mostly silent. Pulmonary Carcinoid is diagnosed by bronchoscopy. Treatment of pulmonary carcinoid is primarily by surgery (3). Surgical modalities include pneumonectomy, lobectomy, segmentectomy, and wedge resection. Chemotherapy and radiotherapy are the treatment of choice in metastasis.CONCLUSIONS: Clinicians should utilize imaging studies to rule out any obstructive lung lesion in patients with refractory wheezing and dyspnea.
Peripheral T-cell lymphomas are an offshoot of non-Hodgkin’s lymphomas and usually carry a poor prognosis. Their clinical manifestations could be very variable and can mimic an infectious or autoimmune etiology. Here, we present a case of a 58-year-old healthy female who presented with fever, cough, and shortness of breath for several days. Imaging studies including chest x-ray and CT scans were suggestive of pleural effusions, mediastinal/retroperitoneal lymphadenopathy, and splenomegaly. She was initially managed for severe sepsis in the setting of possible community-acquired pneumonia. Later her course of hospitalization was complicated by respiratory failure and needing mechanical ventilation and then extracorporeal membrane oxygenation (ECMO). Multiple biopsies were performed including bone marrow and lymph nodes which were suggestive of peripheral T-cell lymphoma - not otherwise specified. Due to the severity of her illness, palliative discussions were made and the family opted for comfort care.
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