1. Through The Looking Glass
Bronchus-Associated Lymphoid Tissue Lymphoma Presenting as Persistent and Enlarging Ground Glass Opacities on CT Chest Imaging
Isaac Tea, MD, MSc, Sharif Ahmed, MD, William Johnson, DO, Elizabeth Williams, DO
Department of Internal Medicine, Lankenau Medical Center, Wynnewood, PA
Bronchus-associated lymphoid tissue lymphoma (BALToma) is an extremely rare sub-type of mucosa-associated lymphoid tissue lymphoma characterized by the aggregation of extranodal, monoclonal B-lymphoid cells near the bronchial epithelium.
It comprises 0.5% of all pulmonary malignancies and less than 1% of all lymphomas.
It often poses a diagnostic dilemma due to its rarity, indolent course with frequently asymptomatic presentation and diverse appearance on CT imaging.
Chest radiography was stable with no acute cardiopulmonary disease.
CT of the Chest showed multifocal patchy airspace disease denoted by ground glass opacities (GGOs) throughout both lungs.
Notably, these GGOs were found to be persistent and/or increased when compared to that performed 3 months prior.
Bronchoscopy was done which identified increased mucopurulent throughout the tracheobronchial tree. Bronchial mucosa was slightly friable but no discreet endobronchial lesions were noted. Washes, brushes and transbronchial biopsy x3 were performed:
Brushings and biopsies identified predominantly bronchial wall with focal alveolated parenchyma showing minimal chronic inflammation.
No evidence of malignancy.
Video-assisted thoracoscopic surgical (VATS) biopsy of the GGOs from the left lung were performed. Pathology and flow cytometric analysis revealed an abnormal B-cell population with an immunophenotypic expression (CD19, CD20, CD45) consistent with extranodal marginal zone B-cell lymphoma.
Positron emission tomography (PET) revealed a hypermetabolic foci corresponding to the GGOs seen in his lungs, reflective of this neoplastic process.
There was no nodal or metastatic disease.
INTRODUCTION
IMAGING & DIAGNOSTIC STUDIES
3 months Prior
On Admission
A 76 year-old Caucasian male with a history of chronic obstructive pulmonary disease (COPD) and a 40 pack year smoking history presented with intermittent fevers and worsening dyspnea of one-month duration.
Three weeks prior, he was treated for a COPD exacerbation with a seven-day course of Levofloxacin and a Prednisone taper with some improvement in his symptoms.
However, his fevers then returned, accompanied by a new cough that was increasingly productive of green-brown sputum.
This was associated with general malaise and a 10-pound unintentional weight loss.
Notably, he was treated for a pneumonia 3 months prior.
SETTING THE STAGE
7 day course of Levofloxacin and Prednisone Taper for concurrent pneumonia and COPD exacerbation.
Esophagogastroduodenoscopy and colonoscopy were normal.
VATS for surgical biopsy and frozen section with concurrent wedge resection of the right lower lobe x2 and upper lobe x1.
Because of the diffuse nature of his disease identified on PET scanning, he was on rituximab monotherapy.
He had acomplete response to Rituximab, and the GGOs resolved on repeat CT of his Chest.
CLINICAL COURSE
Vitals: HR 82, BP 146/68, RR 20 with SpO2 92% on 2L NC, Temp 100.9F.
No JVD or Lymphadenopathy.
Lung auscultation identified diffuse bilateral wheezing and rhonchi.
No edema in extremities
PHYSICAL EXAM
This case highlights the importance of considering BALToma in the differential when CT imaging reveals ground glass opacities that are persistent and/or increasing in size
This is especially true in patients with recurrent pneumonia and/or COPD exacerbations.
The prognosis of BALToma is favorable with 5-year survival rates of over 85%.
The optimal treatment options are not clearly defined and range from observation to surgical resection alone or in combination with chemotherapy and/or radiotherapy.
More recently, the anti-CD20 antibody, Rituximab has been shown to be efficacious in inducing remission, with complete response, since CD20 antigens are typically expressed on BALToma cells.
DISCUSSION
Total WBC count 17.8 K/UL, 84% neutrophils, 2% bands
Sputum cultured normal flora
Acid-Fast Bacilli smear negative, Quantiferon test negative
INITIAL LABORATORY DATA