Critical Care SESSION TITLE: Global Case Report Poster - Miscellaneous SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
A Case of Primary Pulmonary Anaplastic Large Cell Lymphoma Kohei Yoshimine MD*; and Kazunori Tobino MD Iizuka Hospital, Iizuka, Japan
INTRODUCTION: This case report describes a rare presentation of primary pulmonary anaplastic large cell lymphoma (ALCL) and emphasizes the importance of multiple lung nodules with fever. CASE PRESENTATION: A 65-year-old Japanese male presented to the previous hospital with two weeks of fever with productive cough. Chest computed tomography (CT) obtained at that hospital showed multiple lung nodules in both lungs and he was diagnosed as having septic pulmonary embolism. Levoﬂoxacin therapy was started, but his fever and radiographic abnormalities persisted in spite of 10 days treatment. He was referred to our hospital for the deﬁnitive diagnosis. His past medical history included hepatitis C virus (HCV) related cirrhosis diagnosed 18 years ago which was treated with simeprevir, pegylated interferon alfa 2a plus ribavirin therapy one year before. He had no smoking and had quit drinking alcohol 45 years ago. His medications were as follows: amlodipine, esomeprazole, brotizolam, levoﬂoxacin, loxoprofen and rebamipide. He had no family history and allergic history. Vital signs were as follows: heart rate, 98 bpm; respiratory rate,24 breaths per minute; blood pressure, 133/84 mmHg; temperature, 38.2 degrees Celsius; and oxygen saturation, 99% on room air. Physical examination revealed a lot of untreated tooth decay, and no lymphadenopathy. There were tattoo over his whole body, but no injection scar. Breathing and cardiac sounds were normal. Laboratory test values were as follows: white blood cells, 7,470 /mm3; hemoglobin, 12.2 g/dl; platelets, 169,000 /mm3; serum CRP, 8.65 mg/dl; D-dimer, 2.5 mg/ ml; Hepatitis C virus antibody, 15.4 S/CO; tumor markers (CEA, 0.7 ng/ml; CYFRA, 0.7 ng/ml; Pro-GRP, 40.1pg/ml) were within normal limits. Chest x-ray revealed bilateral multiple nodules and on the right middle lung ﬁeld. Contrast-enhanced whole body CT scan revealed multiple round nodules and masses of varying sizes in both lungs, and these lesions were heterogeneously enhanced. Blood, urine and sputum culture grew no microorganisms. Echocardiography showed normal left ventricular wall movement, no valvular disease and vegetation. The additional test values were as follows: Procalcitonin, <0.1; soluble interleukin-2 receptor, 7753U/ ml. The patient had undergone transbronchial lung biopsy (TBLB) of the right middle lung lobe nodule, and pathological examination of TBLB sample revealed middle- to large-sized atypical lymphocytes. Immunohistochemical staining of these cells demonstrated ALK(+), CD30(+), CD3 (+/-), and CD20(-). The patient was diagnosed as having anaplastic large cell lymphoma. The chemotherapy with cyclophosphamide, doxorubicin, vindesine, and prednisone was started, and his condition improved immediately. After 4 cycles of chemotherapy, CT scan demonstrated reduction in number and size of pulmonary nodules. DISCUSSION: Only 0.4% of lymphomas occur in the lung . Low-grade B-cell non-Hodgkin lymphoma (NHL) accounts for 58-87% of cases of primary pulmonary lymphomas in pathological series, and nearly 90% of these cases correspond to mucosaassociated lymphoid tissue-type NHL. To our knowledge, only 22 cases of primary pulmonary ALCL had been reported. Radiographic features were as follows: endobronchial or intratracheal mass, nodule or mass, pleural effusion, consolidation, cavitation and cystic lesion . ALCL consistently expresses the CD30 antigen, usually has a T-cell phenotype, and frequently follows an aggressive clinical course. ALK rearrangement is an important prognostic factor in ALCL, with ALK rearrangementnegative ALCL having a relatively poor prognosis . Our patient was ALK rearrangement-positive ALCL, and multiple pulmonary nodules had a good response to four cycles of chemotherapy. CONCLUSIONS: This patient’s presentation was unique in that primary pulmonary ALCL caused multiple nodules. This case highlights the importance of including ALCL in the differential diagnosis of multiple pulmonary nodules with fever. Reference #1: Ferraro P, Trastek VF, et al. Primary non-Hodgkin’s lymphoma of the lung. Ann Thorac Surg. 2000; 69: 993- 97. Reference #2: Y Hu, P Liu, et al. Diffuse pulmonary inﬁltration by anaplastic lymphoma kinase negative anaplastic large cell lymphoma: A case report and literature review. Respiratory Medicine CME 3 (2010) 260- 262. Reference #3: S H Han, Y H Maeng, et al. Primary anaplastic large cell lymphoma of the lung presenting with acute atelectasis. Thoracic Cancer 5 (2014) 78-81. DISCLOSURE: The following authors have nothing to disclose: Kohei Yoshimine, Kazunori Tobino No Product/Research Disclosure Information DOI:
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
150#4S CHEST OCTOBER 2016