A 53-Year-Old Man Presenting With Diplopia and Cavitary Lung Nodules Ken Junyang Goh, MD, Angela Takano, MD, Mariko Siyue Koh, MBBS, Pei Yee Tiew, MBBS, Choon Seng Chong, MMed, Chee Kiang Tay, MBBS  CHEST  Volume 155, Issue 4, Pages e107-e112 (April 2019) DOI: 10.1016/j.chest.2018.10.021 Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 1 There is failure of left eye abduction on left gaze (arrow), consistent with a left 6th cranial nerve palsy. Reduced wrinkling over the left forehead and reduced left eyebrow elevation due to a 7th cranial nerve palsy are also evident. CHEST 2019 155, e107-e112DOI: (10.1016/j.chest.2018.10.021) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 2 Chest radiograph revealing bilateral pulmonary nodules. CHEST 2019 155, e107-e112DOI: (10.1016/j.chest.2018.10.021) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 3 Chest CT scans demonstrating multiple cavitary lung lesions of various sizes. CHEST 2019 155, e107-e112DOI: (10.1016/j.chest.2018.10.021) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 4 A and B, Brain MRI revealed (A) FLAIR hyperintensity and (B) leptomeningeal enhancement of the left superior cerebellum (arrows). FLAIR = fluid-attenuated inversion recovery. CHEST 2019 155, e107-e112DOI: (10.1016/j.chest.2018.10.021) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 5 Transbronchial lung biopsy. A, Bronchial tissue and adjacent alveolated parenchyma show effacement by extensive fibrinoinflammatory exudates (asterisks), which obliterate histologic detail and therefore require careful examination (H&E; original magnification, ×10). B, Deeper section and higher magnification of the same tissue fragment highlight a focus of intravascular infiltration (arrow) by atypical large lymphoid cells with open chromatin and prominent nucleoli (circles) (PAS; original magnification, ×40). C, Some areas show sheets of polymorphous lymphohistiocytic infiltrates with scattered atypical large lymphoid cells (arrows) (H&E; original magnification, ×40). D, The same area shows positive reaction for EBER-ISH in some of the atypical cells (circles) (original magnification, ×40). EBER-ISH = Epstein-Barr virus-encoded RNA-in situ hybridization; H&E = hematoxylin-eosin; PAS = periodic acid-Schiff. CHEST 2019 155, e107-e112DOI: (10.1016/j.chest.2018.10.021) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 6 Perianal biopsy. A, Tissue section reveals the presence of atypical cells with enlarged nuclei and prominent nucleoli (arrows), convoluted nuclear membranes (circles), and occasional mitotic figure (arrowhead) (H&E; original magnification, ×40). B, Immunohistochemical stain for CD20 highlights numerous scattered B lymphocytes, with a variation in size from moderately to markedly enlarged (original magnification, ×20). C, The larger atypical B cells are highlighted by EBER-ISH stain (original magnification, ×20). D, Immunohistochemical stain for Ki-67 shows a high proliferation rate for the atypical B lymphocytes (original magnification, ×20). See Figure 5 legend for expansion of abbreviations. CHEST 2019 155, e107-e112DOI: (10.1016/j.chest.2018.10.021) Copyright © 2018 American College of Chest Physicians Terms and Conditions