Primary lymphoma of the lung is rare and most are B-cells. We present a case of primary pulmonary T-cell lymphoma (PTCL).CASE PRESENTATIONS: 72-year-old female presented with multilobar pneumonia refractory to antibiotic treatment. Patient underwent 3 fiberoptic bronchoscopies. Bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) showed mixed T lymphocytes, which was believed to be a reactive process. Right pleural effusion and progressive hilar adenopathy ensued. Transthoracic need biopsy (TNB) of the right hilum showed atypical T lymphocytes. Monoclonality could not be established by flow cytometry. Gene rearrangement was unsuccessful due to cell paucity. An open lung biopsy was planned, however, patient declined and desired to go home. She was readmitted with respiratory distress, sepsis and later succumbed. Autopsy revealed PTCL of both lungs and invasive aspergillosis in right upper lobe.DISCUSSION: Pulmonary lymphoma is a rare entity. Most are of B-cell origin and have indolent courses. PTCL is found in < 5% of all pulmonary lymphomas and portends much worse prognosis. Most patients present with B symptoms and ’refractory pneumonia’. Chest CT often shows diffuse air-space disease with lower lobe predilection. Pleural effusion, hilar adenopathy and cavitary lesion have been reported. BAL, TBB, and TNB show mixed, atypical T-cells, which are often regarded as reactive T-cells due to infection. Establishment of monoclonality by flow cytometry and gene rearrangement is vital to the diagnosis. This almost always requires large amount of sample via open lung biopsy. Effective treatment is not known. Most patients succumb within months after diagnosis.
Although rare, PTCL should be considered in patients who deteriorate despite appropriate treatment and persistently show T lymphocytosis in lung specimens. Because of its aggressive nature, timely diagnosis is crucial. Open lung biopsy is often required to establish monoclonality.
P. Laohaburanakit, None.