Simultaneous occurrence of invasive pulmonary aspergillosis and diffuse large B-cell lymphoma: case report and literature review

Case report: Simultaneous occurrence of primary pulmonary lymphoma and opportunistic infections in a patient with chronic myeloid leukemia

Background

The occurrence of primary pulmonary lymphoma (PPL) as a secondary malignancy in patients diagnosed with chronic myeloid leukemia (CML) is extremely rare. As the clinical manifestations are atypical, most patients with PPL tend to be misdiagnosed with pneumonia. When the radiographic features of PPL and pulmonary infection overlap, clinicians can be confused about the diagnosis. Here, we report the first case of coexistence of PPL and opportunistic infections in a patient with CML in chronic phase (CML-CP).

Case presentation

A 55-year-old woman presented with three weeks of hemorrhage of the oral mucosa at the Department of Hematology. After undergoing various examinations, she was diagnosed with CML-CP and was started on imatinib (400 mg/daily). Due to sudden respiratory distress, the patient was admitted to the respiratory intensive care unit 11 months later. Chest computed tomography (CT) revealed ground-glass opacities, patchy shadows, and multiple nodules in both lungs and enlarged mediastinal lymph nodes. The combination of biapenem and voriconazole antibiotic treatments was effective. The patient’s respiratory distress was relieved, but there was intermittent coughing. In the following time, the patient developed a fever, and the imaging findings indicated progression of the disease in both lungs. Bronchoalveolar lavage (BAL) identified pathogens of multiple opportunistic infections. The coexistence of lymphomatoid granulomatosis (LYG) was not confirmed in this patient until a second CT-guided biopsy was performed. Ultimately, the patient underwent chemotherapy in time and is currently alive today.

Conclusions

When the patient’s recurrent respiratory symptoms and imaging findings do not coincide, secondary tumors should be considered in addition to infection as a diagnosis. In these cases, multiple pathological tissue biopsies should be performed.

Disseminated tuberculosis confounding a co-morbid primary CNS lymphoma

Primary central nervous system lymphoma is notoriously challenging to diagnose in immunocompetent patients as it is an uncommon diagnosis. We present a case of synchronous diagnosis with tuberculosis. A 60-year-old woman presented with cognitive difficulties, memory loss, social withdrawal, unintentional weight loss, and night sweats, the work-up of which ultimately identified multiple brain lesions and mediastinal adenopathy. Brain biopsy showed lymphohistiocytic infiltrate, while mediastinal node histopathology showed necrotizing granulomas, and cultures grew Mycobacterium tuberculosis. The patient was initiated on anti-tuberculosis therapy. However, follow-up brain MRI demonstrated disease progression, prompting repeat brain biopsy, which in turn confirmed the diagnosis of diffuse large B-cell lymphoma. Although unrelated synchronous diagnoses are rare, the potential for clinically significant confounding is considerable-particularly where disease markers may overlap, as is often the case with infectious, inflammatory, and neoplastic processes. The present case illustrates the importance of diligence in ruling out competing diagnosis, and timely action when an anticipated finding or response-to-treatment is not observed.