Case 169: Lymphomatoid granulomatosis

Pulmonary lymphomatoid granulomatosis in a 4-year-old girl: A case report

BACKGROUND

Pulmonary lymphomatoid granulomatosis (PLG) is a lymphoproliferative disease associated with Epstein-Barr viral infection occurring mainly in adults and rarely in children. It is characterized by multiple pulmonary nodules. Its diagnosis depends on lung biopsy findings. Most patients are immunodeficient, and it commonly presents in children undergoing chemotherapy for leukemia. We report the case of a child with PLG caused by a mutation in the macrophage-expressed gene 1 (MPEG1), suggesting possible PLG occurrence in children undergoing treatment for pulmonary nodular lesions.

CASE SUMMARY

This study reports a case of PLG without apparent immunodeficiency, suggesting the possibility of this disease occurrence during the treatment of pulmonary nodular lesions in children. Initially, the cause was assumed to be an atypical pathogen. Following conventional anti-infective treatment, chest computed tomography findings revealed that there were still multiple nodules in the lungs. Additionally, the patient was found to be infected with the Epstein-Barr virus. Histopathological examination of the resected lung revealed lymphoproliferative lesions with necrosis. Small lymphocytes, plasma cells, and histiocytes were observed in the background, although Reed-Sternberg cells were absent. Immunohistochemical staining [CD20(+), CD30(+), and CD3(+)] and EBV-encoded small RNA1/2 in situ hybridization of small lymphocytes revealed approximately 200 cells/high-power field. Whole exon sequencing of the patient revealed a mutation in the MPEG1. The patient was eventually diagnosed with PLG and transferred to the Department of Pediatric Oncology for bone marrow transplantation.

CONCLUSION

As PLG is rare and fatal, it should be suspected in clinical settings when treatment of initial diagnosis is ineffective.

Lymphomatoid Granulomatosis Involving the Lung and Brain in a Child: A Case Report

Lymphomatoid granulomatosis (LG) is a rare B-cell type angiocentric lymphoproliferative disease that can progress to extranodal lymphoma with high mortality. It most commonly affects the lungs, although extrapulmonary systems, including the brain and skin, can also be involved. LG in pediatric patients has been very rarely reported in the literature with limited imaging features. Herein, we report a pediatric case of LG involving the lung and brain with characteristic imaging findings.

Approach to Peribronchovascular Disease on CT

Diseases that are predominantly peribronchovascular in distribution on computed tomography by definition involve the bronchi, adjacent vasculature, and associated lymphatics involving the central or axial lung interstitium. An understanding of diseases that can present with focal peribronchovascular findings is useful for establishing diagnoses and guiding patient management. This review will cover clinical and imaging features that may assist in differentiating amongst the various causes of primarily peribronchovascular disease.

Case 233: Blastomycosis

History A 35-year-old man from the upper Midwest region of the United States who had no relevant medical history initially presented to an acute care clinic with multiple small tender skin lesions. His temperature was 38.1°C, and physical examination revealed several small fluctuant masses that were draining purulent material. Skin culture of one of the draining lesions was performed at this time, but there was no subsequent bacterial growth. A diagnosis of furunculosis was made, and Bactrim (sulfamethoxazole-trimethoprim; AR Scientific, Philadelphia, Pa) and a regimen of chlorhexidine washes were prescribed. Two weeks later, the number of skin lesions had increased, and the patient had begun to experience night sweats and fevers. After an episode of hemoptysis and some unusual pain in the patient's right testicle, he presented to the emergency department. At this time, chest radiographs were obtained. The patient was admitted for additional work-up, and computed tomographic (CT) images of the chest were obtained. Physical examination at the time of admission revealed scattered 1-3-cm firm pink hyperpigmented subcutaneous nodules, several of which had overlying pustules. This examination was also notable for a palpable fullness within the right testicle. The patient was afebrile at admission. He denied a history of contact with sick people, illicit drug use, or recent travel. His social history was notable for a 20-pack-year smoking history and a recent relocation to a neighborhood with several new construction sites. Laboratory evaluation revealed leukocytosis (white blood cell count, 15.4 × 10(9)/L; normal range, [3.5-10.5] × 10(9)/L), a chemistry panel revealed a low sodium level (132 mEq/L [132 mmol/L]; normal range, 134-142 mEq/L [134-142 mmol/L]), and serum α-fetoprotein and human chorionic gonadotropin levels were normal. Ultrasonography (US) of the scrotum was performed. Serum analysis was negative for human immunodeficiency virus type 1 and type 2 RNA, and Venereal Disease Research Laboratory and rapid plasma regain test results were negative. Blood cultures were negative for bacterial growth. On the basis of chest CT findings, bronchoscopy with bronchoalveolar lavage was performed. Magnetic resonance (MR) imaging of the abdomen also was performed to further evaluate a focal area of hypoenhancement within the pancreatic tail seen on chest CT images.

Viruses, Immunity and Unusual Lymphoproliferative Disorders of the Chest: Integrating Imaging With Pathogenesis and Clinical Presentations

Unusual lymphoproliferative diseases result from the stimulation of intrathoracic lymphoid tissue by viruses and immune dysfunction, ranging from benign hyperplasia to malignant transformation. We review the clinical, radiological, and histopathological findings of unusual lymphoproliferative disorders, which have been linked to viruses or immune dysfunction, focusing on thoracic manifestations. Understanding these advances in science enhances the radiologist's skills in integrating the imaging findings to the clinical scenario to suggest the correct diagnosis.

Pulmonary lymphomatoid granulomatosis in a 4-year-old girl

Lymphomatoid granulomatosis is a rare lymphoproliferative disease associated with the Epstein-Barr virus that commonly affects the lung. There is limited literature on cases of pediatric lymphomatoid granulomatosis. Half of all cases of lymphomatoid granulomatosis develop during the treatment of leukemia. Herein, we describe a case of lymphomatoid granulomatosis in a previously healthy child without leukemia.