A 59-year-old African American female with a history of type 2 diabetes mellitus (DM) and chronic gastroesophageal reflux disease (GERD) was evaluated in the pulmonology clinic with complaints of persistent dyspnea on exertion (DOE) and cough persistent for six months. She also cited intermittent, generalized abdominal pain and a twelve-pound weight loss in the previous four months. On further inquiry, she reported that she had undergone computed tomography (CT) scan of her chest six years earlier, which showed multiple bilateral nodules. Owing to her refusal, a transbronchial biopsy could not be performed, and her preliminary diagnosis of sarcoidosis was upheld. The patient was a lifelong non-smoker and denied a family history of lung diseases.\nOn clinical exam, the patient was hemodynamically stable with equal air entry bilaterally. Initial laboratory workup including complete blood count and complete metabolic picture were unremarkable. A repeat chest CT scan was obtained, which revealed nodular areas of consolidation in both lungs (). Due to her apprehensions against general anesthesia, a CT-guided right lung biopsy was performed, which disclosed a dense, monotonous population of centrocyte-like cells (). Immunohistochemistry stained positive for CD20, Bcl-2, and CD21 while in situ hybridization (FISH) showed kappa light-chain restriction, which confirmed the diagnosis of a marginal zone lymphoma (MZL) ().\nSubsequent staging investigations included negative bone marrow biopsy and an esophagogastroduodenoscopy (EGD). Gastric biopsies revealed an atypical B-cell lymphoid infiltrate consistent with an extra-nodal marginal zone lymphoma of MALT (). Additionally, Helicobacter pylori stool antigen and immunohistochemistry were negative. The gastric mucosa was involved by a monomorphous small cell lymphoid infiltrate with slightly irregular nuclear contours and moderate pale cytoplasm (centrocyte-like morphology) infiltrating the lamina propria with focal infiltration of the epithelial structures. Immunohistochemistry revealed positivity for CD 20 and a low proliferation index (Ki67).\nIn the ensuing week after staging, the patient was admitted to the inpatient setting with complaints of excessive abdominal pain, nausea, and vomiting. A CT scan of the abdomen and pelvis unveiled a hypo-dense 2.2 cm pancreatic neck. An endoscopic ultrasound (EUS) with biopsy established a new diagnosis of pancreatic ductal adenocarcinoma.\nMedical oncology was consulted for further management, and the patient was started on Gemcitabine and Abraxane, with an outpatient follow-up on a regular basis.
A 63-year-old man presents with a 4-year history of progressive exertional dyspnea and a recurrent productive cough producing white or yellowish sputum. He has a smoking history of 40 pack-years and stopped 4 months ago. He had been admitted to the local hospital many times and received a diagnosis of “COPD with lung abscess.” He was treated with antibiotics, which eased the symptoms. A chest CT showed emphysematous changes throughout and a solitary cavity in the left lower lobe (Fig. A and B). For the recurring symptom, he was referred to our hospital for the further diagnosis and treatment.\nVital signs were normal, and significant physical examination findings included the following: a barrel chest and the breathing sounds with widely dry rales in lung bilaterally. Significant laboratory findings on admission included the following: WBC count, 4.12 ×109/L (48.8% neutrophils and 40.5% lymphocytes); serum tumor makers: CA125 90.56U/mL (normal range <35U/mL), LTA 5.30ng/mL (normal range <3 ng/mL). Spirometry showed an FEV1 of 1.43L (54.3% predicted) and an FEV1/FVC of 61.4%. Arterial blood gas on room air showed a pH of 7.40, Pco2 of 48 mm Hg, and Po2 of 72 mm Hg. Renal function, electrolytes, and coagulation studies were within normal limits. The chest enhanced CT scan is shown in Figure C and D.\nThe patient was started on empiric antibiotic therapy with Ciprofloxacin for yellowish sputum and the cavity of the left lower lobe. Sputum culture showed Escherichia coli, and the antibiotics was not changed. The patient underwent fiberoptic bronchoscopy, which revealed no remarkable findings (data not shown). In spite of that, endobronchial biopsies of bronchus in the left lower lobe were obtained and histological examination showed a diffuse infiltrate of lymphocytes (Fig. A). Immunocytochemically, the lymphoid cells stained positive for CD20 (Fig. B) and Ig Κ (Fig. C), but negative for CD21, CD10, CD3, CD23, and CyclinD1 (data not shown). The positive rate of Ki67 was < 5% (Fig. D). Further, the PCR-based analysis showed IGH, IGΚ gene rearrangement (Fig. ). Afterward, the patient underwent abdominal CT scan, lymph node of neck color Doppler ultrasound, and bone marrow biopsy, which were negative. But he refused to take esophagogastroduodenoscopy, because he had received the exam which was also negative a few months ago in the local hospital. Finally, the patient was diagnosed COPD with pulmonary MZBL of MALT type and treated with CHOP (cyclophosphamide, adriamycin, vincristine, and prednisone) chemotherapy for twice and antibiotics. He is being followed-up for 1 year, with slight progress in pulmonary MZBL of MALT.