A 59-year-old, former smoker, man, presented at the Emergency Department with a sub-acute onset of increasing dyspnea and persistent dry cough. Previous medical history consisted of an occupational exposure to fine dusts and other toxic inhalants (ex pottery maker), and acute myocardial infarction previously treated with PTCA. No symptoms of collagen vascular/autoimmune disease were present.\nAt physical examination, digital clubbing was observed and inspiratory basal crackles were detected. Chest X-rays documented multiple bilateral pulmonary consolidations and a High-Resolution Computed Tomography (HRCT) confirmed the presence of bilateral multiple areas of consolidations with frequent air bronchograms, interlobular septal thickenings and ground-glass opacities (). Imaging was consistent with a crazy paving pattern.\nSputum examination was negative for pathogenic microbes, while pulmonary function tests revealed a moderate restrictive disease (VEMS 66,5%, FVC 61,1%, TLC 56,8%).\nThe post-operative course was unremarkable and the patient was discharged in 4th post-op day. At histology, the lung parenchyma showed nodular lesions characterized by an infiltration monomorphic small lymphocites and plasma-cells obliterating the alveolar spaces () associated with lymphoepithelial lesions (B). At immunohistochemistry, neoplastic lymphocytes show a B-cell clonal phenotype (CD20 immunohistochemistry, Hematoxylin counterstain, 20X (C)); moreover, stain for MIB1 shows a low proliferative index of the neoplastic infiltrate (MIB1 immunohistochemistry, Hematoxylin counterstain, 20X (D)) accounting for 3-5%. The final diagnosis of mucosa-associated lymphoid tissue-derived (MALT) lymphoma was finally made. The patient underwent chemotherapy with Rituximab and Bendamustine, with gradual and progressive improvement of the overall clinical scenario.
The patient is a 63-year-old man with a past medical history of MALToma of the lung who presented with generalized weakness for the past one month associated with cough, fever, night sweats, and shortness of breath. The patient also had anorexia and weight loss of 15 pounds over one month. He denied a history of smoking. The patient was under treatment with isoniazid and pyridoxine for latent tuberculosis based on a positive skin tuberculin test.\nOn physical examination, his blood pressure was 110/59 mmHg, heart rate 118 beats per minute (bpm), respiratory rate 18/min, saturating 99% on room air with a temperature of 98.9oF. The patient was in no cardiopulmonary distress. A cardiovascular examination revealed no jugular venous distension, normal S1-S2, and no murmurs. On lung auscultation, the patient had rales at the left lung base.\nLaboratory data showed sodium 134 mEq/L, potassium 4.2 mEq/L, chloride 103 mEq/L, bicarbonate 25 mEq/L, blood urea nitrogen 17 mg/dl, creatinine 0.9 mg/dl, glucose 96 mg/dl, hemoglobin 6.6 g/dl, hematocrit 20.1%, white blood cell count 5.5 x 103/microliter, and platelets 128 x 103/microliter. The coagulation profile showed prothrombin time (PT) 17.2 sec, partial thromboplastin time (PTT) 44.3 sec, and international normalized ratio (INR) 1.38.\nChest X-ray (CXR) and computed tomography (CT) scan showed right middle lobe opacity (Figures -). Repeat imaging after six months showed multiple masses in the lung and an osteoblastic bone lesion involving the left ilium (Figures -). Esophagogastroduodenoscopy showed a normal gastro-esophageal junction with erythematous mucosa in the stomach. The gastric biopsy was normal.\nA lung biopsy done at initial presentation from the right middle lobe mass showed dense lymphoid infiltrate with proliferation of monocytoid B lymphocytes consistent with extranodal marginal zone lymphoma (BALToma/MALToma).\nA CT-guided core needle biopsy from the left posterior pelvic mass that was noted six months after the initial presentation showed high grade diffuse large B-cell lymphoma involving skeletal muscles. The pathology report showed diffuse proliferation of lymphocytes, which were positive for cluster of differentiation (CD) 20 and B-cell lymphoma (BCL)-2 by immunohistochemistry tests. He was started on chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) with subsequent complete clinical and radiologic remission (Figure ).