Lymphomatoid Granulomatosis

Misdiagnosis of lymphoma as vasculitis: A case report

NK/T-cell lymphoma (NKTCL) is a highly aggressive malignant tumour with a very poor prognosis, which often poses diagnostic difficulties due to the non-specificity of its clinical presentation. NK/T-cell lymphoma with eosinophilic hyperplasia syndrome is extremely rare. This article describes a patient with NKTCL misdiagnosed as vasculitis who presented with sinusitis, abdominal pain, anorexia, and lung shadows. Additionally, the patient exhibited extremely high eosinophilia levels, which led to a further misdiagnosis of eosinophilic granuloma. We describe the clinical features, diagnostic methods and differential diagnosis of lymphoma and highlights the importance of a multidisciplinary approach in accurate diagnosis and treatment.

[DRESS syndrome induced by anti-TB drugs]

OBJETIVE

To describe the phenotype of DRESS syndrome induced by antituberculosis drugs.

METHODS

Descriptive study, withdrawn from the review of the records of patients with DRESS syndrome, identified in the interconsultation of the Department of Research in Immunogenetics and Allergy, of the Insti-tuto Nacional de Enfermedades Respiratorias (INER) Ismael Cosío Villegas, among 2014 and 2020. Frequency analysis was performed. The associations between biomarkers and latency are calculated with the χ2 test and log-rank, and the evaluation of the change in the biomarkers with the Wilcoxon test. The value of p < 0.05 is considered statistically significant. For data analysis, the SPSS v.21 program was obtained.

RESULTS

15 patients were identified; represented by 0.02% of total cases treated in the Department for so-meimmuno-allergic condition (15/7052); the main symptomatology were: rash (100%), eosinophilia (93%), fe-ver (80%), adenomegaly (60%), kidney damage (40%), liver damage (33%), and latency of 21 days. Liver damage was associated with prolonged latency (p = 0.02). After treatment, the total levels of eosinophils (p < 0.001) and liver and kidney biomarkers (p < 0.04) decreased. DRESS syndrome induced by antituberculosis drugs is not associated with the number of drugs prescribed or with the pattern of resistance of Mycobacterium tuberculosis.

CONCLUSIONS

DRESS syndrome induced by antituberculosis drugs is an atypical clinical reaction, similar to other types of DRESS syndrome that respond favorably to systemic corticosteroids.

Lymphomatoid granulomatosis with the central nervous system involvement as the main manifestation: a case report

BACKGROUND

Lymphomatoid granulomatosis (LyG) is a rare extralymphatic lymphoproliferative disease characterized by lymphocytic invasion into vascular walls and damage to blood vessels. The lungs are affected in 90% of LyG cases, followed by the skin, central nervous system (CNS), kidneys and liver.

CASE PRESENTATION

Here we report a case of a young woman with LyG, with CNS involvement as the initial clinical manifestation. Computer tomography (CT) scans showed multiple nodular, patchy and flocculent high-density shadows in both lungs without mediastinal lymph node enlargement. Magnetic resonance imaging (MRI) scans showed multiple abnormal signal intensities in the right cerebellar hemisphere, frontal, parietal and temporal lobes, and dorsal brainstem, which became patchy and annular after enhancement. The post-operative pathological analysis of lesion samples confirmed the diagnosis of grade II LyG.

CONCLUSIONS

LyG should be concerned in young adults showing multiple radiological brain and lung lesions. Resection and postoperative medication of steroid hormones and IFN-α may be effective in the treatment of LyG.

18F-FDG PET/CT Imaging of a Grade 3 Lymphomatoid Granulomatosis in an Immunocompromised Pediatric Patient

Lymphomatoid granulomatosis is a rare extranodal Epstein-Barr virus-driven B-cell lymphoproliferative disease, involving predominantly lung, less often skin, kidney, and central nervous system. Here, we present a pediatric case with primary immunodeficiency, diagnosed with pathologically proven pulmonary grade-III lymphomatoid granulomatosis. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging demonstrated ¹⁸F-FDG avid pulmonary masses with central air-bronchograms and cavitations. Although the definitive diagnosis depends on biopsy, ¹⁸F-FDG PET/CT serves as a complementary imaging tool to evaluate the extent of the disease and response to treatment.

[Combined immunodeficiency due to DOCK8 deficiency. State of the art]

Combinedimmunodeficiency (CID) due to DOCK8 deficiency is an inborn error of immunity (IBD) characterized by dysfunctional T and B lymphocytes; The spectrum of manifestations includes allergy, autoimmunity, inflammation, predisposition to cancer, and recurrent infections. DOCK8 deficiency can be distinguished from other CIDs or within the spectrum of hyper-IgE syndromes by exhibiting profound susceptibility to viral skin infections, associated skin cancers, and severe food allergies. The 9p24.3 subtelomeric locus where DOCK8 is located includes numerous repetitive sequence elements that predispose to the generation of large germline deletions and recombination-mediated somatic DNA repair. Residual production DOCK8 protein contributes to the variable phenotype of the disease. Severe viral skin infections and varicella-zoster virus (VZV)-associated vasculopathy, reflect an essential role of the DOCK8 protein, which is required to maintain lymphocyte integrity as cells migrate through the tissues. Loss of DOCK8 causes immune deficiencies through other mechanisms, including a cell survival defect. In addition, there are alterations in the response of dendritic cells, which explains susceptibility to virus infection and regulatory T lymphocytes that could help explain autoimmunity in patients. Hematopoietic stem cell transplantation (HSCT) is the only curative treatment; it improves eczema, allergies, and susceptibility to infections.

A Case of Lymphomatoid Granulomatosis Presenting as a Cervical Mass

An 89-year-old man presented with the chief complaint of a sore throat and a mass in the right side of his neck that tended to increase in size. He displayed the right Horner's sign, and imaging findings showed a 65-mm mass in the right side of the neck, invading the carotid artery. There were no other obvious lesions. The differential diagnosis was carcinoma of an unknown primary or neurogenic tumor. An incisional biopsy was performed, and the pathological diagnosis was lymphomatoid granulomatosis. The patient was started on oral prednisolone, but the disease progressed, and his general condition worsened. Therefore, supportive care was provided. This was a very rare case of a cervical lesion of lymphomatoid granulomatosis.

High-grade Primary Central Nervous System Lymphomatoid Granulomatosis: Successful Rituximab Monotherapy

The primary central nervous system (CNS) presentation of lymphomatoid granulomatosis (LYG) is rare, and no standard therapy for LYG with primary CNS symptoms exists. CNS-LYG patients usually survive for only less than a year from diagnosis. This is the first report of high-grade primary CNS-LYG with monoclonality that was successfully treated with rituximab monotherapy, resulting in a durable remission for more than 1 year in a 66-year-old woman with pemphigus vulgaris who was also on immunosuppressive therapy.

Lymphomatoid Granulomatosis in HIV-2: A Rare Entity

Lymphomatoid granulomatosis (LYG) is a rare B-cell lymphoproliferative disorder associated with Epstein-Barr virus (EBV) infection and is frequently associated with immunodeficiency. Pulmonary involvement with angiocentric distribution is the most common clinical manifestation. Diagnosis is confirmed by tissue biopsy, usually from lung lesions. Due to the paucity of reported cases, there is no validated treatment for LYG. Therapeutic options include interferon-alpha, systemic corticosteroids, rituximab, chemotherapy, and autologous hematopoietic stem cell transplantation. We report a case of a 49-year-old man, with human immunodeficiency virus type 2 (HIV-2) infection, who was diagnosed with LYG with lung involvement and had a full remission after treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone).

Molecular Properties and Therapeutic Targeting of the EBV-Encoded Receptor BILF1

The γ-herpesvirus Epstein-Barr Virus (EBV) establishes lifelong infections in approximately 90% of adults worldwide. Up to 1,000,000 people yearly are estimated to suffer from health conditions attributed to the infection with this virus, such as nasopharyngeal and gastric carcinomas as well as several forms of B, T and NK cell lymphoma. To date, no EBV-specific therapeutic option has reached the market, greatly reducing the survival prognoses of affected patients. Similar to other herpesviruses, EBV encodes for a G protein-coupled receptor (GPCR), BILF1, affecting a multitude of cellular signaling pathways. BILF1 has been identified to promote immune evasion and tumorigenesis, effectively ensuring a life-long persistence of EBV in, and driving detrimental health conditions to its host. This review summarizes the epidemiology of EBV-associated malignancies, their current standard-of-care, EBV-specific therapeutics in development, GPCRs and their druggability, and most importantly consolidates the findings of over 15 years of research on BILF1 in the context of EBV-specific drug development. Taken together, BILF1 constitutes a promising target for the development of novel EBV-specific therapeutics.

A case of central nervous system lesion pathologically characterized by angiocentric, T-cell-rich lymphoid cell infiltrates: a case report and literature review

Lymphomatoid granulomatosis (LYG) is a rare lymphoproliferative disease with angiocentric and angiodestructive infiltrates, and by definition, Epstein-Barr virus (EBV)-associated B-cell malignancy. It most frequently involves the lung, and in some cases, the lesions are confined to the central nervous system (isolated CNS-LYG). However, it remains a controversial disease in terms of pathophysiology, especially in those confined to the CNS. We report the case of a 37-year-old man with CNS lesion pathologically characterized by angiocentric, T-cell-rich lymphoid cell infiltrates that resembled CNS-LYG. The lesion was clinically aggressive with subacute onset and irregular ring-like enhancement on MRI. The resected specimen showed no cytological atypia, EBV-infected cells, or monoclonality for IgH and TCR gene rearrangements. Considering the possibility of latent malignancy, the patient was successfully treated with corticosteroid and chemoradiotherapy with high-dose methotrexate. The present case and the literature suggest that EBV-negative CNS lesions with angiocentric lymphoid infiltrates are probably heterogeneous in their pathogenesis, including those that could fit into the so-called CNS-LYG and those with T-cell predominance. The accumulation of similar cases is warranted for the classification and appropriate treatment of these lesions.

Lymphomatoid granulomatosis in one patient with newly diagnosed HIV infection and Kaposi's sarcoma: a case report and literature review

Lymphomatoid granulomatosis is a very rare B cell lymphoproliferative disease associated with Epstein-Barr virus infection. It is related to states of immunosuppression and affects the lung in more than 90% of cases, forcing the clinician to establish a differential diagnosis with other diseases such as infections, Wegener's granulomatosis, lymphoma, or lung metastases. There is no standard treatment for this disease. In this paper, we describe a rare case of a patient with grade 3 lymphomatoid granulomatosis with newly diagnosed HIV infection who started antiretroviral treatment with a gradual improvement of the lesions.

Angioinvasive lymphoma (lymphomatoid granulomatosis) in a cat, with cutaneous and ocular metastasis

Lymphomatoid granulomatosis (LYG) is a rare variant of an angioinvasive T-cell lymphoproliferative disorder that primarily affects the lungs, with common sites of metastasis including the skin and subcutis. In humans, it is a B-cell lymphoproliferative disorder associated with Epstein-Barr virus infection. Our case is a 7-y-old, spayed female, domestic longhair cat that decompensated and was euthanized following an initial diagnosis of angioinvasive lymphoma from a skin biopsy. Autopsy revealed nodules in the lungs and subcutis, and corneal thickening and cloudiness. Histologic examination of cutaneous nodules, lungs, and eye showed similar angioinvasive cellular infiltrates and pattern to that of the original skin biopsy, consistent with a diagnosis of LYG. The neoplastic cells displayed CD3-positive immunoreactivity in the skin, eye, and lung, and PCR for antigen receptor rearrangement (PARR) showed T-cell clonality in all tissues tested. This is the third case of LYG to be reported in cats and is the only case in which PARR analysis and immunophenotyping immunohistochemical staining was performed. LYG with ocular involvement has not been reported previously in cats, to our knowledge. Our case demonstrates the necessity for considering LYG when presented with a cat with respiratory signs in conjunction with subcutaneous nodules and ocular lesions.

Primary Pulmonary B-Cell Lymphoma: A Review and Update

Simple Summary

The group of B-cell lymphomas primarily involving the lung encompasses different histological entities with distinct biological aspects, while sharing some clinical and radiological features related to their common anatomic site of occurrence. Recent molecular advances in the molecular genetics of these lesions have substantially improved of our understanding of the mechanisms of lymphomagenesis, adding novel information to histology in order to better characterize and manage these diseases. This review summarizes the available clinical, radiological, pathological, and molecular data on primary pulmonary B-cell lymphomas, discusses the mechanisms of lymphomagenesis, and highlights the role of a multi-disciplinary management in overcoming the diagnostic and therapeutic challenges in this setting.

Abstract

Primary pulmonary B-cell lymphomas (PP-BCLs) comprise a group of extranodal non-Hodgkin lymphomas of B-cell origin, which primarily affect the lung without evidence of extrapulmonary disease at the time of diagnosis and up to 3 months afterwards. Primary lymphoid proliferations of the lung are most often of B-cell lineage, and include three major entities with different clinical, morphological, and molecular features: primary pulmonary marginal zone lymphoma of mucosa-associated lymphoid tissue (PP-MZL, or MALT lymphoma), primary pulmonary diffuse large B cell lymphoma (PP-DLBCL), and lymphomatoid granulomatosis (LYG). Less common entities include primary effusion B-cell lymphoma (PEL) and intravascular large B cell lymphoma (IVLBCL). A proper workup requires a multidisciplinary approach, including radiologists, pneumologists, thoracic surgeons, pathologists, hemato-oncologists, and radiation oncologists, in order to achieve a correct diagnosis and risk assessment. Aim of this review is to analyze and outline the clinical and pathological features of the most frequent PP-BCLs, and to critically analyze the major issues in their diagnosis and management.

Pathobiology and treatment of lymphomatoid granulomatosis, a rare EBV-driven disorder

Lymphomatoid granulomatosis (LYG) is a rare Epstein-Barr virus (EBV)-driven B-cell lymphoproliferative disease (LPD). This disease is hypothesized to result from defective immune surveillance of EBV, with most patients showing evidence of immune dysfunction, despite no known primary immunodeficiency. Pathologically, LYG is graded by the number and density of EBV+ atypical B cells, and other characteristic findings include an angioinvasive/angiodestructive reactive T-cell infiltrate and various degrees of necrosis. Clinically, LYG universally involves the lungs with other common extranodal sites, including skin, central nervous system, liver, and kidneys. Nodal and/or bone marrow involvement is extremely rare and, if present, suggests an alternative diagnosis. Treatment selection is based on histologic grade and underlying pathobiology with low-grade disease hypothesized to be immune-dependent and typically polyclonal and high-grade disease to be immune-independent and typically oligoclonal or monoclonal. Methods of augmenting the immune response to EBV in low-grade LYG include treatment with interferon-α2b, whereas high-grade disease requires immunochemotherapy. Given the underlying defective immune surveillance of EBV, patients with high-grade disease may have a recurrence in the form of low-grade disease after immunochemotherapy, and those with low-grade disease may progress to high-grade disease after immune modulation, which can be effectively managed with crossover treatment. In patients with primary refractory disease or in those with multiple relapses, hematopoietic stem cell transplantation may be considered, but its efficacy is not well established. This review discusses the pathogenesis of LYG and highlights distinct histopathologic and clinical features that distinguish this disorder from other EBV+ B-cell LPDs and lymphomas. Treatment options, including immune modulation and combination immunochemotherapy, are discussed.

An atypical case of a pulmonary mass in an immunocompromised patient

OBJECTIVES

Pulmonary lymphomatoid granulomatosis (PLG) is a rare angiocentric and angiodestructive EBV-associated lymphoproliferative disorder which almost always affects the lungs. PLG is more commonly diagnosed in patients with immunodeficiency and is associated with Epstein-Barr virus (EBV). 'Drug induced PLG' or 'iatrogenic immunodeficiency-associated lymphoproliferative disorder' is a special form of PLG described in patient with inflammatory bowel diseases treated with Azathioprine.

METHODS

We report a case of drug-induced PLG in a 68-year-old patient with Crohn's disease presenting with pain at the right hemithorax, fatigue and shortness of breath with a pulmonary mass.

RESULTS

Although initial diagnostic findings were misleading, an open lung biopsy eventually led to the diagnosis of drug-induced PLG.

CONCLUSION

The diagnosis of PLG is challenging because the disease is rare and the histological features can be very subtle. Correct diagnosis relies on histopathology and immunohistochemical staining and EBV RNA in situ hybridization with sampling of large and different amounts of pathologic tissue in the hands of expert pathologists. In drug-induced PLG specifically, withdrawal of the immunosuppressive agent can lead to disease regression.

A rare case of severe right heart failure due to pulmonary artery lymphomatoid granulomatosis

Lymphomatoid granulomatosis is a rare, vascular-centric, and vessel-destroying lymphoproliferative disease that hardly involves the pulmonary arteries. Herein, we report a case with severe right heart failure and pulmonary arterial stenosis caused by pulmonary artery lymphomatoid granulomatosis. This case was diagnosed by percutaneous transluminal pulmonary artery biopsy and was effectively treated with stent implantation and steroid administration.

A Case Report of a Female Patient With Hodgkin Lymphoma Localized in the Central Nervous System and With Concomitant Pulmonary Lymphomatoid Granulomatosis

The involvement of the central nervous system (CNS) in Hodgkin lymphoma (HL) has been rarely reported, especially in its primary isolated form. Herein, we present a case of a 33-year-old woman, who received immunosuppressive treatment due to ulcerative colitis (at the beginning azathioprine and sulfasalazine, changed to mesalazine), with repetitive episodes of loss of consciousness for a few weeks and with no other symptoms. Magnetic resonance imaging scans of the head revealed a tumor in the lateral part of the left temporal lobe and in the cerebellum. Moreover, a subsequent computed tomographic scan of the chest revealed diffuse tumorous lesions in the lungs. The brain tumor was resected and a tumorous lesion resected from the lungs was biopsied. The histopathological analysis confirmed the final diagnosis of HL localized in the CNS with concomitant pulmonary lymphomatoid granulomatosis (LYG) grade 1. After the patient underwent radiotherapy and chemotherapy, the patient showed complete regression of lesions in the CNS and lungs, which was confirmed by positron emission tomographic scan. LYG and CNS-HL are rare proliferative disease derived from lymphocytes B and associated with EBV infections. An association between LYG and other autoimmune disorders has been reported, but to the best of our knowledge, this is the first case of the CNS-HL associated with lymphatoid granulomatosis.

Use of rituximab in lymphomatoid granulomatosis with isolated central nervous system involvement

A 33-year-old woman presented to the emergency room with severe headaches. A CT scan of the head revealed two brain lesions with associated vasogenic oedema. Diagnostic resection of one of the lesions followed by pathological analysis revealed grade III lymphomatoid granulomatosis (LYG). Staging investigations elsewhere in the body were negative, isolating this case of LYG to the central nervous system, an atypical presentation. After the resection, she was treated with single-agent rituximab 375 mg/m² The follow-up MRI demonstrated the resolution of brain lesions and no progression of the disease.

Neuroimages and Neuropathology of a Stroke-Like Cerebral Lymphomatoid Granulomatosis

A 70-year-old man presented to the Emergency Department reporting the acute onset of non-fluent aphasia, hyposthenia, and hemi-anesthesia of the right body. Brain computerized tomography revealed a subcortical hypodense lesion in the middle cerebral artery territory. Neck ultrasounds of internal and external carotid arteries and of the vertebral arteries showed a focal moderate stenosis of the left internal carotid artery due to a soft atheromasic plaque. These findings that were initially consistent with a diagnosis of an ischemic stroke were not confirmed by magnetic resonance (MR). The latter showed an hyperintense lesion on FLAIR and T2-weighted sequences located in the left centrum semiovale, corona radiata, and thalamus, with a well-defined regular rim and a mild compressive effect on the lateral ventricle, with diffusivity restriction but without ADC reduction and with a punctate and serpiginous gadolinium enhancement on T1 sequences (Figure 1). Within the first day of observation, the patient started complaining progressive mental deterioration, in absence of any other possible causes, and a total body CT scan excluded any other organ involvement. Patient was then referred to the neurosurgeon in order to perform a brain biopsy. The neuropathology was compatible with the diagnosis of cerebral lymphomatoid granulomatosis (LG) (Figure 1).

Mimickers of pulmonary lymphoma

There are multiple entities that involve the lung that have radiographic, clinical, and morphologic overlaps with pulmonary lymphoma. In this review, we will discuss these entities in detail and provide relevant updates.

Update on the Management of Respiratory Manifestations of the Antineutrophil Cytoplasmic Antibodies-Associated Vasculitides

Antibody-associated vasculitis comprises 3 small vessel vasculitis syndromes: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic polyangiitis (EGPA). This article outlines the major tracheobronchial and pulmonary parenchymal disease manifestations of GPA and MPA and their management, as well as relevant recent advances in the treatment of EGPA. Shared trends in the management of all 3 syndromes are: (1) a focus on glucocorticoid avoidance and (2) an increasing reliance on biologic agents. Evidence from randomized controlled trials and large cohort studies in support of these trends as well as ongoing research efforts are summarized.

Pulmonary Lymphomatoid Granulomatosis With Hemophagocytic Lymphohistiocytosis as the Initial Manifestation

Lymphomatoid granulomatosis (LYG) is an extremely rare angio-centric and angio-destructive B-cell lymphoproliferative disease. Driven by Epstein-Barr virus (EBV), LYG predominantly involves the bilateral lungs. Commonly presenting as multiple nodules in the lung, pulmonary LYG can masquerade as various infectious diseases, vasculitis, lung cancer, or other metastatic neoplasm. It is difficult to be diagnosed and is always neglected by clinicians. No standardized therapeutic regimens for LYG has been established yet now. Hemophagocytic lymphohistiocytosis (HLH), a life-threatening condition caused by abnormal activation of macrophages and T-cells, is characterized by fever, hepatosplenomegaly, pancytopenia, hypercytokinemia, and the presence of hemophagocytosis within the bone marrow, liver, spleen, or other lymphatic tissue. We herein report a 55-year-old man with recurrent fever, severe jaundice, and multiple high-density opacities and nodules in both lungs, who was finally diagnosed with pulmonary LYG (Grade 3) manifested with secondary HLH. Administration of HLH-1994 protocol led to the rapid control of the symptoms caused by HLH. Rituximab-based combination therapy was useful yet LYG (Grade 3) progressed rapidly. This case demonstrates that tissue biopsy is essential for early pathological diagnosis and effective treatment of LYG.

A 53-Year-Old Man Presenting With Diplopia and Cavitary Lung Nodules

CASE PRESENTATION

A 53-year-old Chinese man presented with 1 week of worsening diplopia and left-sided facial droop. His symptoms developed during a readmission for elective drainage and curettage of a perianal abscess that recurred despite drainage 2 weeks before. He denied having other neurologic symptoms, and did not report any cough, sputum production, night sweats, or fever. He was a lifelong nonsmoker with a history of polymyositis treated with mycophenolate mofetil for the last 4 years. He had undergone surgical resection for jejunal adenocarcinoma 12 years prior to this presentation. No evidence of recurrence was detected on surveillance gastrointestinal endoscopies and CT scans.

Epstein - Barr virus positive T and NK-cell lymphoproliferations: Morphological features and differential diagnosis

The spectrum of Epstein-Barr virus (EBV)-positive T and NK-cell lymphoproliferations is broad and ranges from reactive self-limited disorders to neoplastic processes with a fulminant clinical course. EBV plays an important role promoting lymphomagenesis, although the precise mechanisms remain elusive. EBV-positive lymphoproliferative disorders (LPD) are more common in East Asia (China, Japan, Korea and Taiwan), and Latin America suggesting a strong genetic predisposition. The revised 2016 World Health Organization (WHO) lymphoma classification recognizes the following malignant NK- and T-cell lymphomas; extranodal NK/T-cell lymphoma, nasal type (ENKTCL), aggressive NK-cell leukemia (ANKL), and the provisional entity within the group of peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS) "primary EBV-positive nodal T or NK cell lymphoma". Disorders presenting mainly in children and young adults include chronic active EBV infection (CAEBV) - systemic and cutaneous forms - which are not considered malignant disorders but were included in the WHO classification for the first time because of the differential diagnosis with other T- or NK-cell lymphomas. CAEBV, cutaneous form, includes hydroa vacciniforme-like LPD (HV-LPD) and severe mosquito bite allergy (SMBA). Finally, systemic EBV-positive T-cell lymphoma of childhood was recognized as lymphoma because of its fulminant clinical course. Given the shared pathogenesis of these disorders, overlapping features are common demanding a close clinical, morphological and molecular correlation for an accurate diagnosis. This review summarizes the clinical, histopathological and molecular features of EBV-associated T and NK-cell LPD, highlighting the main features that might aid in the differential diagnosis.

Isolated lymphomatoid granulomatosis of the central nervous system: A case report and literature review

Lymphomatoid granulomatosis (LYG) is an angiocentric and angiodestructive lymphoproliferative disease which can involve multiple organs of the body and is most common in the lungs. Its pathological features are proliferation of large atypical B-cells related to Epstein-Barr virus, T-cell infiltration and tissue necrosis. This disease is rare, and LYG which uniquely involves the central nervous system (CNS) is extremely rare. In this paper, we report a case of isolated lymphomatoid granulomatosis of the CNS (iCNS-LYG) diagnosed by histological biopsy and we review the clinical features of all similar cases reported in the past 46 years. A total of 49 cases of iCNS-LYG have been reported to date. The clinical, imaging and pathological features of iCNS-LYG are discussed in combination with a literature review.

Primary pulmonary lymphoma: imaging findings in 30 cases

PURPOSE

To present our experience of cases of primary pulmonary lymphoma (PPL) found between January 2002 and July 2018, focusing on the radiological features and the differential diagnosis in order to contribute to the difficult role of the radiologist in the disease identification and to help the clinicians to reach the diagnosis.

MATERIALS AND METHODS

CT scans of 30 patients (14 men and 16 women, aged 58-86, mean age 72 years) with PPL were retrospectively reviewed. All patients had a histopathological confirmation of the disease: MALT lymphoma (23 patients, 76.6%); diffuse large B-cell lymphoma-DLBCL (seven patients, 23.4%). All the staging CT scans were evaluated by three experienced radiologists dedicated to thoracic disease in order to radiologically define the predominant pattern of presentation.

RESULTS

The following parenchymal patterns were observed: 11 patients with single/multiple nodules, five with masses/mass-like consolidations, 14 with consolidations with air bronchogram, 16 with ground-glass opacity, ten with angiogram sign, 22 with perilymphatic and/or peribronchovascular spread, 15 with associated lymphadenopathies, and 13 with pleural/chest wall involvement. The main characteristics of PPLs were the presence of consolidations and ground-glass opacities, with perilymphatic and/or bronchovascular spread.

CONCLUSION

All the characteristics of the work should alert the radiologist to consider lymphoma among the possible differential diagnoses, always correlating the results of the CT examination with appropriate clinical laboratory evaluations.

CLIPPERS and its mimics: evaluation of new criteria for the diagnosis of CLIPPERS

OBJECTIVE

To evaluate the accuracy of the recently proposed diagnostic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS).

METHODS

We enrolled 42 patients with hindbrain punctate and/or linear enhancements (<3 mm in diameter) and tested the CLIPPERS criteria.

RESULTS

After a median follow-up of 50 months (IQR 25-82), 13 out of 42 patients were CLIPPERS-mimics: systemic and central nervous system lymphomas (n=7), primary central nervous system angiitis (n=4) and autoimmune gliopathies (n=2). The sensitivity and specificity of the CLIPPERS criteria were 93% and 69%, respectively. Nodular enhancement ( ≥ 3 mm in diameter), considered as a red flag in CLIPPERS criteria, was present in 4 out of 13 CLIPPERS-mimics but also in 2 out of 29 patients with CLIPPERS, explaining the lack of sensitivity. Four out of 13 CLIPPERS-mimics who initially met the CLIPPERS criteria displayed red flags at the second attack with a median time of 5.5 months (min 3, max 18), explaining the lack of specificity. One of these four patients had antimyelin oligodendrocyte glycoprotein antibodies, and the three remaining patients relapsed despite a daily dose of prednisone/prednisolone ≥ 30 mg and a biopsy targeting atypical enhancing lesions revealed a lymphoma.

CONCLUSIONS

Our study highlights that (1) nodular enhancement should be considered more as an unusual finding than a red flag excluding the diagnosis of CLIPPERS; (2) red flags may occur up to 18 months after disease onset; (3) as opposed to CLIPPERS-mimics, no relapse occurs when the daily dose of prednisone/prednisolone is ≥ 30 mg; and (4) brain biopsy should target an atypical enhancing lesion when non-invasive investigations remain inconclusive.

Unique case of trigeminal neuralgia due to Epstein-Barr-virus-associated B-cell lymphomatoid granulomatosis of the Meckel's cave and cavernous sinus: Important clinical and therapeutic implications

Background:

Trigeminal neuralgia (TN) represents one of the most disabling pain syndromes. Several diseases have been described as etiological triggers of TN, vascular compression of the trigeminal nerve being the most frequent cause. Here, we describe for the first time a rare case of TN caused by an infiltration of an isolated Epstein–Barr virus (EBV) B-cell lymphomatoid granulomatosis (LYG) mass into the Meckel's cave and cavernous sinus.

Case Description:

A 51-year-old woman undergoing immunosuppressant treatment for Crohn's disease presented due to right-sided TN. Magnetic resonance imaging (MRI) scans revealed an isolated lesion affecting the right Meckel's cave and lateral wall of the cavernous sinus. We accomplished tumor resection through a subtemporal extradural approach and the patient recovered successfully from surgery. Histological examination revealed an LYG, and a blood test confirmed low but positive EBV counts. The immunosuppressant therapy was discontinued and we assumed a watchful waiting management. During a 41-months’ follow-up there was neither evidence of LYG recurrence nor an increase of EBV counts.

Conclusions:

LYG, an angiodestructive disease associated with EBV reactivation in the context of immune dysfunction and often associated with an aggressive behavior or even malignant transformation, should be considered as a rare differential diagnosis of TN associated with skull base lesions. The management of this rare disease is still controversial and varies from limiting the treatment to correcting immune dysfunction up to chemotherapy. In this case of an isolated mass, surgical excision and discontinuation of immunosuppressants were effective to prevent the relapse of the disease in a long-term follow-up.

B cell-rich non-neoplastic sentinel lesion preceding primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) is an uncommon tumor in the brain. Although most PCNSL are readily diagnosed as diffuse large B cell lymphoma (DLBCL) on the first biopsy, very rare cases have been described in which the first detected intracerebral lesions are non-neoplastic, and are composed mostly of perivascular T cells, not B cells. This phenomenon is known as “sentinel lesions.”

A Case of Hodgkin Lymphoma Mimicking Lymphomatoid Granulomatosis Diagnosed at Autopsy

Hodgkin lymphoma and lymphomatoid granulomatosis (LYG) are entities that contain a small number of large, variably Epstein-Barr virus (EBV)-positive neoplastic cells scattered within background non-neoplastic mixed inflammatory infiltrate. The 2 entities can typically be distinguished histologically by the angiocentric and angiodestructive pattern of lymphomatoid granulomatosis (LYG); also, they differ in overall prognosis. Herein, we report a case of Hodgkin lymphoma in a 64-year-old Caucasian woman, diagnosed at autopsy with unusual histologic features and aggressive clinical course that mimicked LYG.

Primary lymphomatoid granulomatosis in the central nervous system: A report of three cases

Lymphomatoid granulomatosis (LYG) is a rare lymphoproliferative disorder characterized by infiltration of Epstein-Barr virus (EBV)-positive large atypical B-cells in an angiocentric fashion in a mixed inflammatory background. The histologic spectrum of LYG ranges from reactive proliferation to diffuse large B-cell lymphoma according to the number of EBV+ B-cells. It is known that virtually all patients have pulmonary involvement, whereas primary LYG of the other organs has been rarely reported. Herein, we describe three cases of primary LYG of the central nervous system (CNS) without pulmonary lesions, and this is the first collection to be reported in Korea. All of the cases revealed multifocal enhancing necrotic brain lesions masking as metastatic tumors, infection or vasculitis. These patients were successfully managed by corticosteroids and immunomodulating agents without chemotherapy against malignant lymphoma even in grade 3 LYG. We assume that primary CNS LYG might be less aggressive and more controllable than pulmonary LYG. The clinicopathologic characteristics of the cases with a special regard to the differential diagnosis and clinical courses are discussed in combination with an overview of the literature.

Oral Manifestation of Lymphomatoid Granulomatosis

Lymphomatoid granulomatosis (LYG) is a rare B-cell lymphoproliferative disorder driven by Esptein-Barr virus (EBV) that most commonly affects the lungs, although extra pulmonary sites like the central nervous system, skin, liver and kidney can also be involved. It is microscopically characterized by an angiocentric and angiodestructive growth pattern, predominantly composed by small T-cells, although a smaller population of atypical large B-cells is considered the true neoplastic component. Oral cavity involvement of LYG has rarely been described and the diagnosis of this neoplasm is very difficult. The aim of this report is to present a rare case of LYG affecting an 86-year-old female patient that was diagnosed due to an extensive, ulcerated and painful oral lesion affecting the hard palate. Detailed microscopic evaluation together with a large immunohistochemical study were necessary to achieve the correct diagnosis of LYG.

Hodgkin's lymphoma and its association with EBV and HIV infection

Hodgkin's lymphoma (HL) constitutes a clonal expansion of what appears to be malignant B cells. Viruses are involved in its pathogenesis, such as the Epstein-Barr virus (EBV) and human immunodeficiency virus (HIV). Since these viral infections have been shown to play key roles in the pathogenesis of HL, countries with a prevalence of HIV and EBV represent interesting population targets to study the pathogenesis of HL, linking the evolution of the disease with viral infections. Usually, patients present with late stage disease often involving the bone marrow at the time of diagnosis. The present paper discusses the role of viral infection in African countries, as HL is considered to be a malignant disease characterized by an inflammatory reaction to an aberrant B cell clone that is well known as the Reed-Sternberg cell (HRS).

Granulomatosis with polyangiitis (Wegener's granulomatosis): a rare variant of sudden natural death

Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is the most common form of life-threatening small-vessel vasculitis. Although its exact pathogenesis remains unclear, GPA is believed to belong to the wide complex of autoimmune diseases due to the presence of anti-neutrophil cytoplasmatic antibodies with cytoplasmic staining pattern (c-ANCA) that is expressed in activated neutrophils. GPA predominantly manifests at the upper and lower respiratory tract and the kidneys, but the impairment of multiple organ systems is possible as well. The so-called classical clinical triad of GPA comprises sinusitis, pneumonia, and glomerulonephritis. Despite the fact that there is an elevated risk of mortality for patients suffering from GPA, sudden death due to GPA is a rare and difficult differential diagnosis of sudden natural death in forensic case work. In the present article, the rare case of a 41-year-old male, who died of a sudden death due to previously undiagnosed GPA, is demonstrated. The final diagnosis was feasible by close interdisciplinary collaboration, considering the entire body of findings obtained during autopsy, histopathological investigation, and analysis of the clinical records. Therefore, it remains necessary to point out that especially for rare causes of death, interdisciplinary collaboration is essential in order to concretize the cause of death and exclude rare differential diagnoses of sudden unexpected death of hospitalized patients in forensic case work.

Rare case of pulmonary lymphomatoid granulomatosis in conjunction with tuberculosis: A case report

RATIONALE

Lymphomatoid granulomatosis is a very rare Epstein-Barr virus-driven lymphoproliferative disease. This disease has high mortality owing to its low incidence in conjunction with nonspecific presentations, which contribute to delays in diagnosis.

PATIENT

An 87-year-old male had a week-long history of intermittent fever and general weakness. A chest radiograph showed multifocal patchy consolidations with nodular lesions.

DIAGNOSES

Open lung biopsy using video-assisted thoracic surgery resulted in a diagnosis of grade III lymphomatoid granulomatosis. Three days after surgery, Mycobacterium tuberculosis complex was identified from the culture of sputum samples collected at admission.

INTERVENTION AND OUTCOMES

Antituberculous treatment was commenced first. However, after 34 days of antituberculosis medication, the patient died owing to aggravated lymphomatoid granulomatosis.

LESSONS

This case highlights the fact that rare diseases should also be considered in differential diagnosis, particularly with a common presentation such as multiple lung nodules. Furthermore, a diagnosis of pulmonary lymphomatoid granulomatosis was made after open lung biopsy. To our knowledge, this is the first case of lymphomatoid granulomatosis coexisting with active tuberculosis in the Republic of Korea, where tuberculosis is endemic.

Aggressive B-cell lymphomas in the update of the 4th edition of the World Health Organization classification of haematopoietic and lymphatic tissues: refinements of the classification, new entities and genetic findings

The update of the 4th edition of the World Health Organization Classification of Haematopoietic and Lymphatic Tissues portends important new findings and concepts in the diagnosis, classification and biology of lymphomas. This review summarizes the basic concepts and cornerstones of the classification of aggressive B-cell lymphomas and details the major changes. Of importance, there is a new concept of High-grade B-cell lymphomas (HGBL), partly replacing the provisional entity of B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma (DLBCL) and Burkitt lymphoma, the so-called grey zone lymphomas. They either harbour MYC translocations together with a BCL2 and/or a BCL6 rearrangement (HGBL-Double Hit) or HGBL, not otherwise specified (NOS), lacking a double or triple hit constellation. In addition, the requirement for providing the cell-of-origin classification in the diagnostic work-up of DLBCLs, the role of MYC alterations in DLBCL subtypes, and newer findings in the specific variants/subtypes are highlighted.

Pathogenesis and FDG-PET/CT findings of Epstein-Barr virus-related lymphoid neoplasms

Epstein-Barr virus (EBV) is one of the most common viruses, infecting more than 90% of the adult population worldwide. EBV genome is detected in some lymphoid neoplasms. Not only their histopathological subtypes, but also their backgrounds and their clinical courses are variable. A number of B-cell lymphoproliferative disorders associated with the immunocompromised state are related to EBV infection. The incidences of these disorders have been increasing along with generalization of organ transplantations and use of immunosuppressive treatments. Furthermore, some EBV-positive lymphoma can also occur in immunocompetent patients. While evaluating patients with generalized lymphadenopathy of unknown cause by positron emission tomography/computed tomography with 2-deoxy-2-[¹⁸F]fluoro-D-glucose (FDG-PET/CT), the possibility of lymphoid neoplasms should be considered in some patients, and a careful review of the background and previous history of the patients is necessary. In this review article, we describe the pathogenesis of EBV-related lymphoid neoplasms and then present FDG-PET/CT images of representative diseases. In addition, we also present a review of other EBV-related diseases, such as infectious mononucleosis and nasopharyngeal carcinoma.

Lymphomatoid granulomatosis with pulmonary and gastrointestinal involvement

We present a rare case of grade II lymphomatoid granulomatosis (LYG) with pulmonary and gastrointestinal involvement. LYG is considered an Epstein-Barr virus-driven lymphoproliferative disorder that often presents with multiple nodular lesions in the lungs and sometimes involvement of skin and the central nervous system. Although the aetiology is unknown, it is associated with the use of immunosuppressives. Involvement of other organ systems is very rare. We successfully treated our patients with 6 cycles of R-CHOP and autologous stem cell transplantation with a major response at 20 months follow-up.