Tissue Is the Issue: Case of Primary Pulmonary Peripheral T Cell Lymphoma

Abstract

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.