INTRODUCTION: B-cell lymphoma usually presents as a constillation of symptoms such as weight loss, fevers, loss of appetite and fatigue along with physical exam and radiographic evidence lymphadenopathy. We present a case of lymphoma presenting primarily as a pleural effusion without physical exam or radiographic findings of enlarged lymph nodes.
CASE PRESENTATION: The patient is an 83 year old male who came to the emergency room with weakness, increasing shortness of breath and lower extremity swelling. He has a history of metastatic prostate cancer, diabetes, congestive heart failure, deep venous thrombosis, and was recently discharged from the hospital for gram negative sepsis. On examination, he was cachectic with no palpable lymph nodes but with a firm mass felt on the abdominal left upper quadrant and left flank. He had decreased breath sounds over the left thorax with dullness to percussion up to the third intercostal space. A helical CT of the chest to rule out pulmonary embolism was performed which revealed no embolism, but showed a large left pleural effusion, numerable non-enlarged mediastinal lymph nodes and blastic lesions within the cervical spine. Ultrasound of the abdomen showed a normal-sized spleen (10.7x3.2cm). A diagnostic and therapeutic thoracentesis was performed which revealed 6,800 nucleated cells and 14,800 red blood cells. The lactate dehydrogenase (LDH) in pleural fluid is 1411 and glucose of 46 with serum glucose of 105 and LDH of 935. Cytology of the nucleated cells revealed CD10 positive large B-cell lymphoma.
DISCUSSION: In patients with metastatic disease, the possibility of a new primary cannot be excluded. In this case, the pre-existing diagnosis of prostate cancer and multiple bone lesions would have led to an incorrect conclusion that the prostate cancer was the source of the pleural effusion, especially in the setting of bone metastasis. As only a small portion of metastatic prostate cancer presents with abnormalities on chest radiography, further examination of the pleural fluid was definitely warranted. This rare presentation of B-cell lymphoma underscores the reason that tissue is necessary prior to treatment.
CONCLUSIONS: n this case, large B-cell lymphoma primarily in the pleural fluid was diagnosed in a patient with another known malignancy. It is important to have a broad differential when a new pleural effusion is discovered.
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DISCLOSURE: The following authors have nothing to disclose: Irtza Sharif, Navneet Arora, Mark Regala, Christina Migliore
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