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Pleural Effusion as the Only Manifestation of Lymphoma FREE TO VIEW

Samuel Copeland, MD; Venu Madhav Konala, MD; Raed Alalawi, MD; Irfan Warraich, MD
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Texas Tech University Health Sciences Center, Lubbock, TX

Chest. 2014;146(4_MeetingAbstracts):649A. doi:10.1378/chest.1987638
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SESSION TITLE: Cancer Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Pleural Effusion is a common diagnosis in medicine. All pleural effusions of unknown origin should undergo diagnostic evaluation with fluid analysis. Specific studies, such as cytological evaluation, are important to determine the underlying etiology.

CASE PRESENTATION: We report a 50 year old African American male with a history of human immunodeficiency virus infection who presented to the emergency room with dyspnea, associated with dry cough and lateral chest pain. He denied fever, chills, night sweats, weight loss, and fatigue. Physical examination revealed severely diminished breath sounds as well as dullness to percussion over the left chest to upper lung zones. A chest radiograph demonstrated large left-sided pleural effusion; thoracentesis was performed. Fluid analysis revealed grossly bloody effusion with 44,200 RBC/mm3 and 6,638 WBC/mm3 (16% lymphocytes, 5% macrophages and 79% lymphoma cells). LDH and protein content were elevated at 1,577 IU/L and 5.0 g/dL respectively. Immunohistochemistry revealed positive markers for CD20, CD79a, BCL2, and Ki-67 of 90% representing a high grade B cell lymphoma. A CT of the neck, chest, abdomen, and pelvis demonstrated irregular, thickened parietal pleura with a lobulated appearance; no lymphadenopathy was identified. Immunostains as well as serology for both human herpesvirus 8(HHV-8) and Epstein-Barr virus were negative. A diagnosis of extranodal high grade B-cell lymphoma was made. The patient was given options for treatment, but declined and elected for hospice care.

DISCUSSION: Initially after reviewing the cytopathology and imaging studies, we thought the patient had primary effusion lymphoma (PEL). However as per WHO classification, PEL patients must have evidence of infection with HHV-8 (1). If HHV-8 is absent an alternate diagnosis must be considered. Carbone et al' suggested how to further classify effusion lymphomas based upon clinical, morphological, and biological characteristics (2). More recently, Wu et al' further delineated HHV8 negative effusions based on immunophenotypic features (3). Considering this data our case could be classified as KSHV/HHV8-unrelated PEL-like lymphoma. Treatment involves Rituximab with different chemotherapy regimens, depending on the subtype of malignancy identified.

CONCLUSIONS: This case illustrated a unique lymphoma with no associated lymphadenopathy or infection of HHV-8; treatment modalities remain limited with an overall poor prognosis.

Reference #1: Swerdlow, Steven H. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France: International Agency for Research on Cancer, 2008. Print.

Reference #2: Carbone, A., and A. Gloghini. 2008. PEL and HHV8-unrelated effusion lymphomas: classification and diagnosis. Cancer 114: 225-227.

Reference #3: Wu, W., W. Youm, S. A. Rezk, and X. Zhao. 2013. Human herpesvirus 8-unrelated primary effusion lymphoma-like lymphoma: report of a rare case and review of 54 cases in the literature. Am J Clin Pathol 140: 258-273.

DISCLOSURE: The following authors have nothing to disclose: Samuel Copeland, Venu Madhav Konala, Raed Alalawi, Irfan Warraich

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