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Pleural involvement in Non-Hodgkin Lymphoma (NHL) is well documented, but primary pleural lymphomas are extremely rare, occurring mostly in immunosuppressed patients or associated with chronic pleural inflammation. Nevertheless, the pathogenesis and therapeutic approaches to counteract primary pleural lymphomas are still matter of debate. The authors present the clinical case of an 81-year-old female with respiratory and constitutional symptoms. A valvular heart disease and bilateral pleural effusion were known. The study carried out showed a large right pleural effusion; the fluid analysis was compatible with Diffuse Large B-cell Lymphoma (DLBCL), and two lymphomatous masses with pleural origin were found at the ipsilateral hemithorax. Primary pleural lymphoma was considered and chemotherapy was initiated with a good response and evolution. The authors report this remarkable clinical case because of its rarity, its excellent clinical evolution and the absence of an immunodeficiency context.

Tuberculous pericarditis is a rare extra-pulmonary manifestation of tuberculosis observed mainly in developed countries. It usually presents with concomitant tuberculous infection at a different site and, due to the lack of clinical specificity, diagnosis can be difficult. Thus, a diagnostic delay is frequent, entailing increased morbidity and mortality. The authors present a case of disseminated tuberculosis with predominantly cardiac symptoms with multiple negative samples for Mycobacterium tuberculosis, which evolved to constrictive pericarditis. With this case report, the authors emphasize the demand for a high index of suspicion for achieving a diagnosis and the importance of a multidisciplinary approach.

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Synchronous tumours are complex cases, being challenging to distinguish between primary neoplasms and metastatic disease, as well as to accurately determine the origin of metastasis. Although synchronous tumours are relatively rare, its incidence has increased over the years. The authors report on a patient with localized clear cell renal carcinoma and synchronous adenocarcinoma of the lung with solitary brain metastasis, highlighting the uncertainties of the therapeutic approach and the implications to the final outcomes.

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Epstein-Barr virus (EBV) is a double-stranded virus that shows tropism for B-cell lymphocytes. EBV-infected patients usually present with tonsillitis/pharyngitis, cervical lymphadenopathy and fever, but an atypical presentation can mimic lymphoproliferative disease. We present the case of a 77-year-old woman with asthenia, fever, oral ulcers and peripheral lymphadenopathy. After extensive evaluation, including anatomopathological and immunocytochemical examination of excisional lymph node biopsy samples, it was still not clear whether the patient had EBV infection or diffuse large B-cell lymphoma. In this case report, the authors describe how it can be difficult to differentiate between two different, although related, entities, making diagnosis of lymphoma highly challenging. LEARNING POINTS Lymph node biopsy findings may result in lymphoma being misdiagnosed as acute Epstein-Barr virus infection. Immunophenotypic analysis can occasionally be insufficient to establish the clonal nature of the disease. Timely diagnosis of lymphoma is necessary so that immunochemotherapy can be initiated and clinical improvement achieved.

Hemophagocytic lymphohistiocytosis poses a diagnostic dilemma due to the absence of specific clinical and laboratory findings, especially in adults. Despite greater recognition of the disease, secondary idiopathic forms are still reported.