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.
An 83-year-old male with past medical history of mild Alzheimer's dementia, nonischemic cardiomyopathy, aortic regurgitation, and an ascending aortic aneurysm measured at 4.1 cm presented to the pulmonology clinic with an abnormal CT of the chest. He was seen by his PCP recently for follow-up of ascending aortic aneurysm and had a CT chest without contrast performed which showed 14.8 mm pleural-based nodular density in the posterior medial right upper lobe, irregular 20.5 mm right lower lobe nodule, and a 2 mm left upper lobe partially calcified nodule []. He had no respiratory or constitutional symptoms. He was a lifelong nonsmoker without any significant occupational exposures. [18F]Fluorodeoxyglucose-positron emission tomography with CT (18F –FDG PET/CT) was performed showing multiple 18F –FDG avid nodules in the right upper lobe, right lower lobe, and left upper lobe []. Initially thought to be inflammatory in nature, a 3-month follow-up CT chest was recommended; however, the patient opted for CT-guided transthoracic biopsy. Because the tissue sample was a core needle biopsy of a pleural-based nodule, it did not include any bronchial epithelium; therefore, the presence of lymphoepithelial lesions could not be evaluated. Immunohistochemical staining showed CD20 positive neoplastic B cells with CD3 positive small benign T cells. CD21 stain was also positive within the residual dendritic cell network, such that the marginal zones appeared to be expanded. These findings support a histopathologic diagnosis of low-grade B-cell NHL most consistent with marginal zone lymphoma []. The patient was referred to oncology for further management.