INTRODUCTION: Endotracheal or endobronchial involvement from non-pulmonary tumors is rare. Of the numerous ways that lymphoma can affect the lungs, endobronchial infiltration is less common than mediastinal adenopathy and nodules. We present a case in which Non-Hodgkin’s Lymphoma manifested as necrotizing tracheobronchitis leading to respiratory failure which has not been previously described.
CASE PRESENTATION: A 40 year old male non-smoker of Middle Eastern descent presented with three week history of sore throat refractory to antibiotics. He had accompanying fever, dysphagia, and twenty pound weight loss. Upon presentation he was found to have profound anemia, melena and a large peritonsillar mass. Oro/nasopharyngeal necrotic mass was surgically resected. Subsequent esophagogastroduodenoscopy revealed an ulcerative-infiltrative process involving the distal esophagus and stomach. Biopsies from the tonsils and esophagus revealed diffuse large B-cell lymphoma. On hospital day 6 he developed acute hypoxemic respiratory failure requiring intubation. CT pulmonary angiogram showed diffuse bilateral pulmonary nodules and ground glass without evidence of pulmonary embolism. Bronchoscopy demonstrated diffuse necrotizing ulcerative infiltration throughout his trachea and bronchi. Endobronchial biopsies confirmed diffuse large B-cell lymphoma with tissue necrosis. Microbiological evaluation from broncho-alveolar lavage and other sources failed to reveal infection. Chemotherapy was initiated. Bronchoscopy 2 weeks later showed improvement of endobronchial process after one round of chemotherapy. Hospital course was complicated by prolonged respiratory failure, opportunistic infections and progression of his lymphoma.
DISCUSSIONS: Review of literature describes Non-Hodgkin’s Lymphoma of the lungs to manifest in four different patterns - nodular, pneumonic/alveolar, bronchovascular/lymphangitic and miliary/hematogenous. Only a small number of case reports have demonstrated lymphoma involving the airways. To better assess its prevalence, a post mortem study of 51 patients with Non-Hodgkin’s lymphoma revealed that none of the patients had endobronchial involvement validating its infrequent incidence. In 1983, Rose et al described 2 types of endobronchial involvement by lymphoma - “Type 1” as diffuse sub-mucosal infiltration in patients with clinically apparent systemic lymphoma often in addition to parenchymal involvement and “Type 2” as a localized solitary endobronchial mass. “Type 2” is an atypical form of primary pulmonary lymphoma arising from extranodal mucosa-associated lymphatic tissue (MALT) of the airways. “Type 1” is believed to occur due to endobronchial metastasis through lymphatic spread into the peri-bronchial connective tissue. “Type 2” endobronchial lymphoma has been more frequently reported in recent literature mainly as case reports, while “Type I” descriptions are rare. Patients with both types of endobronchial involvement generally may remain asymptomatic. However, when symptoms develop they are typically hemoptysis, cough and atelectasis secondary to endobronchial obstruction. Respiratory failure due to extensive endotracheal and endobronchial involvement has not been described in previous case reports.
CONCLUSION: Infiltrative endobronchial involvement of lymphoma is a rare manifestation. Lymphoma should be considered in the differential diagnosis of necrotizing tracheitis and bronchitis. Lymphoma may present as acute respiratory failure in these situations closely mimicking a necrotizing infection.
DISCLOSURE: Baljinder Sidhu, No Financial Disclosure Information; No Product/Research Disclosure Information