Primary pleural lymphoma: an unusual presentation of childhood non-Hodgkin lymphoma

Primary pleural lymphoma of T cell origin in a paediatric patient with a focus on radiological findings - a case report and review of literature

Purpose

Pleural lymphoma is a medical condition characterised by shortness of breath and obscure chest pain, which may be a diagnostic challenge, especially when it occurs in children. Plain chest X-rays and computed tomography (CT) scan are the main imaging techniques and are the initial diagnostic methods utilised.

Case report

A four-year-old boy was admitted to the emergency ward with pain in the right thoracoabdominal region, which had persisted for two months. Physical examination revealed reduced respiratory sounds in the right chest, but with no other significant findings. The patient underwent chest X-ray and CT scan, which showed right sided pleural thickening coupled with a massive pleural effusion. The patient underwent pleural biopsy, and a diagnosis of T-cell primary pleural lymphoma was made. The patient underwent treatment with BFM-NHL and was followed for three years, during which the patient remained disease free.

Conclusions

Pleural lymphoma is a rare diagnosis especially in children and could have overlapping clinical manifestations with more common conditions. Imaging techniques are the main route of clinical work-up towards final diagnosis. Here, we present a rare paediatric patient with no significant past medical history, who underwent imaging and was diagnosed with T-cell primary pleural lymphoma, a very rare subtype of primary pleural lymphoma.

Primary Effusion Lymphoma (PEL)-Like Lymphoma in a Child With Congenital Immunodeficiency

Primary effusion lymphoma (PEL) is a rare lymphoma that occurs more frequently in immunocompromised adults and has a poor survival. We report a 9-year-old female with combined immunodeficiency with an Epstein-Barr virus positive/human herpes virus 8 negative PEL-like lymphoma. The treatment with systemic chemotherapy for non-Hodgkin lymphoma, zidovudine, and interferon-α failed to control disease progression. This is the first reported pediatric case of PEL-like lymphoma. Increased diagnostic awareness and more effective treatment strategies are needed for this rare lymphoma.

Unexpected finding of T-cell lymphoma in a previously healthy 16-year-old patient after a thorax trauma: a case report

Introduction

We describe the clinical course and emphasize the difficulties in diagnosing T-cell lymphoblastic lymphoma. The differential diagnostic difficulties have previously been described in regard to pneumonia, but to the best of the authors’ knowledge this is the first case report to describe lymphoma in relation to trauma.

Case presentation

A previously healthy 16-year-old Danish boy presented to our hospital with chest pain and accentuated protruding thoracic veins. Ten days prior to hospitalization he had suffered a blunt thoracic trauma while playing soccer. After drainage of an excessive amount of pleural fluid, he developed severe respiratory distress. A chest tube was inserted and he was transferred to a level 1 trauma centre. Here, a computed tomography scan unexpectedly revealed significantly swollen mediastinal and retroperitoneal lymph nodes, and he was later diagnosed with T-cell lymphoblastic lymphoma.

Conclusions

This case emphasizes the importance of reacting to an unexplained large amount of pleural fluid after a patient suffers thoracic trauma and to consider possible underlying causes. This report is mainly addressed to emergency personnel, but it is also relevant to pediatricians, surgeons, anesthesiologists, and general practitioners.

Primary pleural non-Hodgkin lymphoma in a child--an exceedingly rare disease

Primary pleural lymphomas are very rare. Two types are described in the literature: primary effusion lymphoma, in the setting of human immunodeficiency virus infection, and pyothorax-associated lymphomas, with a strong Epstein-Barr virus association. We report a rare case of a primary pleural lymphoma in a 12-year-old immunocompetent girl who presented with a hemorrhagic pleural effusion and had plaque-like thickening of the pleura. The histologic and immunophenotypic findings conformed to that of a diffuse large B-cell lymphoma (CD20 positive).

Pleural Effusions in Hematologic Malignancies

Nearly all hematologic malignancies can occasionally present with or develop pleural effusions during the clinical course of disease. Among the most common disorders are Hodgkin and non-Hodgkin lymphomas, with a frequency of 20 to 30%, especially if mediastinal involvement is present. Acute and chronic leukemias, myelodysplastic syndromes, are rarely accompanied by pleural involvement. Furthermore, 10 to 30% of patients receiving bone marrow transplantation develop pleural effusions. In cases of hematologic pleural effusions, drug toxicity, underlying infectious, secondary malignant or rarely autoimmune causes should be carefully sought. In most cases, the pleural fluid responds to treatment of the primary disease, whereas resistant or relapsing cases may necessitate pleurodesis.

An unusual case of primary effusion lymphoma in a HIV-negative patient not pathogenetically associated with HHV8

The development of an unusual case of primary pleural effusion in a 90-year-old human immunodeficiency virus (HIV)-negative Japanese woman with no identifiable tumor mass has been described. Pleural effusion specimens contained large diffuse lymphoma cells, with the phenotype and genotype of a B-cell lineage (positive for CD20, CD79a and clonal rearrangement of Ig heavy chain) and the c-myc gene rearrangement, but were negative for T-cell markers (CD45RO and CD3). The patient was negative for human herpes virus 8 (HHV8), Epstein-Barr virus (EBV) and hepatitis C virus (HCV), as well as human T-cell lymphotropic virus type-1 (HTLV-1). The patient died of respiratory failure 5 months after the diagnosis of primary effusion lymphoma (PEL), and an autopsy was performed. Autopsy findings revealed no evidence of tumor mass or bone marrow involvement of lymphoma cells. This case has been considered as a PEL in a HIV-, HHV8-, EBV- and HCV-negative patient. Although cytomorphology of lymphoma cells was classified as large-cell lymphoma in this case, it is interesting that the present case may represent an unusual subset of Burkitt-like disease because of clear B-cell phenotype and c-myc gene rearrangement.