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 ).
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.