Intravascular Large B-Cell Lymphoma Presenting with Diffusely Increased Pulmonary FDG Up-take withou

Posted By Jayden Spencer
Intravascular Large B-Cell Lymphoma Presenting with Diffusely Increased Pulmonary FDG Up-take withou

ABSTRACT A 60-year-old male presented with complaints of dyspnea, intermittent fever, and 40 pounds of weight loss over the previous nine months and was admitted for acute hypoxemic respiratory failure. Labs demonstrated elevated inflammatory markers, mild anemia, and thrombocytopenia. Fluorodeoxyglucose (FDG) positron emission tomography (PET) scan demonstrated diffuse pulmonary FDG uptake without corresponding abnormality on computed tomography (CT) im-ages. Lung biopsy demonstrated intravascular large B-cell lymphoma (IV-LBCL). Presentation, imaging findings, and diagnosis of IV-LBCL will be discussed, as well as differential considera-tions for isolated pulmonary involvement by IV-LBCL. CASE REPORT A 60-year-old male presented to the emergency department (ED) with chief complaint of dysp-nea and was admitted for acute hypoxemic respiratory failure. The patient reported recurrent, intermittent fever up to 102 degrees Fahrenheit and 40 pounds of weight loss over the previous nine months. Medical history was significant for hospitalization one month prior to this admission for pancyto-penia and splenomegaly. A splenectomy was performed after biopsy demonstrated marginal zone lymphoma of the spleen. Bone marrow biopsy performed at that time was negative. Family history revealed similar presentation of unknown etiology by the patient’s mother, despite exten-sive medical workup in the months prior to her death. Labs on admission demonstrated mild anemia and thrombocytopenia. Inflammatory markers, including C-reactive protein and erythrocyte sedimentation rate, were significantly elevated alt-hough white blood cell count and differential were normal and infectious workup was negative. Liver transaminases were mildly elevated. Initial imaging evaluation ordered by the ED included CT angiogram of the chest for pulmonary embolism, which was negative and demonstrated no significant findings. Further extensive imaging workup was obtained after admission including echocardiogram, CT abdomen and pelvis with contrast, and CT maxillofacial scans. No signifi-cant abnormalities were present. A PET-CT scan was ordered to evaluate for recurrence of prior splenic marginal zone lympho-ma. PET-CT demonstrated no metabolically active adenopathy or abnormal splenic uptake to support recurrence. There was, however, the unusual finding of diffusely increased FDG uptake throughout both lungs without corresponding abnormality on CT (Figure 1). Pneumonitis was considered although there were no CT findings to support this diagnosis. This prompted a litera-ture search to explain the findings. A case report of diffuse pulmonary uptake on FDG-PET with normal CT diagnosed as biopsy-proven intravascular lymphoma was found upon literature review. This study was referenced and differential diagnoses of intravascular lymphoma versus pneumonitis were included in the PET-CT report. Bronchoalveolar lavage was performed and flow cytometry was negative. Due to

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