A 64-year-old Caucasian male presented to the emergency room complaining of progressive fatigue, light-headedness, shortness of breath, and an intermittent cough. He reported waking up with extreme malaise and inability to ambulate on the day of presentation. However, upon further questioning, it became evident that his symptoms had started 3 months prior and had gradually progressed in severity. He had been on a camping trip in the Rocky Mountains of Colorado and stayed in a yurt for one and half months before presentation; the trip was cut short due to his shortness of breath and decreased exercise tolerance. He had seen his primary care provider for these symptoms and a chest X-ray showed bilateral upper and lower lobe alveolar infiltrates. He was treated for atypical pneumonia with a 5-day course of azithromycin. His cough resolved but there was no improvement in the rest of his symptoms. Review of systems was significant for unintentional weight loss of 8–10 pounds over a period of 2 years; he denied nausea, vomiting, diarrhea, and/or melena.\nHis medical history included hypertension, glaucoma, and hyperlipidemia. He was a former smoker, having quit about 20 years prior. He drank alcohol occasionally. Family history was significant for leukemia in his father.\nPhysical examination was significant for pale skin and conjunctiva and a 3/6 systolic murmur best heard at the left sternal border.\nLaboratory investigations showed hematocrit of 11.3% and hemoglobin of 3.7 gm/dl, and the stool guaiac test was positive. Computed tomography (CT) of the chest with intravenous contrast showed bilateral pulmonary opacities and mediastinal lymphadenopathy in the perivascular and posterior mediastinum (). CT of the abdomen and pelvis with contrast showed severe gastric wall thickening involving the proximal body and fundus with surrounding inflammatory changes (). Esophagogastroduodenoscopy with biopsy was performed. Gastric pathology showed an intense infiltrate of small, mature lymphocytes extending to the epithelium and obliteration of normal glandular architecture; immune-histochemical staining showed CD20+ and abnormal dim CD43 co-expression ( and ) and BCL2+ and low to moderate Ki-67 proliferation index suggestive of extra-nodal marginal zone B-cell lymphoma of mucosal-associated lymphoid tissue. Helicobacter pylori was not identified on immunohistochemical staining and a serological analysis of IgG antibodies was negative ruling out previous exposure. A HLA-DQ pattern analysis for celiac disease was inconclusive. Serological analysis to rule out chronic infective etiology for immune stimulation from blastomyces, coccidioides, histoplasma, legionella, mycoplasma, aspergillus, and hepatitis B or C was negative. Subsequently, he also underwent bronchoscopy with transbronchial biopsy of the right upper and middle lobes, which showed atypical lymphoid infiltrate consistent with involvement from known MALT lymphoma with CD20+ and dim CD43 co-expression ( and ). He was treated symptomatically for anemia with blood transfusion and intravenous iron administration. He underwent radiation therapy for MALT lymphoma of the stomach due to gastric bleeding and severe anemia requiring multiple transfusions. Radiation treatment was given with 15 MV photons with an AP/PA treatment technique using MLC shaping with CT based three-dimensional treatment and planning. He received a total dose of 36.0Gy in 20 fractions over 27 elapsed days. Immunotherapy with rituximab was considered. However, since the only symptomatic manifestations were related to his severe anemia secondary to the gastric involvement of his lymphoma, he was treated as localized disease. He is been closely followed by his oncologist and has been undergoing surveillance CT-scan of his chest/abdomen every 6 months and yearly PET scan. He has not required any chemotherapy or further radiation therapy and his lymphoma has remained stable.
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.