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A6947 - Simultaneous Diagnosis of Active Pulmonary Tuberculosis and B-Cell Non-Hodgkin’s Lymphoma with Pleural Involvement
Author Block: D. P. Katzman1, M. F. Sloane2; 1New York University School of Medicine, New York, NY, United States, 2NY Pulm Assoc, New York, NY, United States.
Introduction:
Tuberculosis and lymphoma can both present with constitutional symptoms and similar radiographic features including parenchymal disease, lymphadenopathy, and pleural effusions. We report a patient diagnosed simultaneously with active pulmonary tuberculosis and non-Hodgkin’s lymphoma (NHL) who initially had a chronic dry cough and later constitutional symptoms in the setting of worsening radiographic abnormalities.
Description:
61-year-old male with no significant past medical history and without tuberculosis risk factors underwent a chest CT in the setting of trauma, which demonstrated an incidental focal lingular opacity without lymphadenopathy or pleural effusions. Six months later, chest X-ray showed lingular and right middle lobe consolidations with an associated small left pleural effusion. His only symptom was a chronic dry cough. An additional three months later, chest CT was repeated after he developed fevers, chills, fatigue, and worsening dry cough. Follow up chest CT showed persistent right middle lobe and lingular consolidations, bilateral clustered opacities, an enlarged subcarina lymph node, a large right pleural effusion, and a trace left pleural effusion. He was treated with levofloxacin without improvement. His HIV status was negative. QuantiFERON®-TB Gold assay was indeterminate. Right sided pleural fluid was remarkable for a lymphocyte predominant exudative effusion. Additional pleural fluid analysis revealed a negative bacterial culture, pH of 7.9, normal adenosine deaminase at 8.3-U/L, and cytology was remarkable for an increased number of mature lymphocytes.
After completing levofloxacin, repeat chest CT demonstrated progressive parenchymal abnormalities including new right sided cavitary nodules, and an enlarging left pleural effusion. Low-grade B-cell NHL was diagnosed by flow cytometry from left sided pleural fluid and subcarinal lymph node needle aspiration. Tuberculosis was diagnosed by positive AFB smear and PCR for mycobacterium tuberculosis from a lingular bronchoalveolar lavage specimen. Trans-bronchial lingular biopsies demonstrated sparse atypical lymphoid aggregates. Pleural fluid was AFB smear negative and mycobacterial culture had no growth after three weeks. Lymphoma treatment was initially deferred in setting of active infection. He was started on isoniazid, rifampin, pyrazinamide, and ethambutol with resolution of constitutional symptoms.
Discussion:
Even when diagnosed simultaneously, tuberculosis and lymphoma may develop sequentially. Immunosuppression secondary to lymphoma can increase the risk of reactivation tuberculosis. Conversely, previous literature has suggested an association between active tuberculosis and the development of NHL in the era before effective anti-mycobacterial chemotherapy, perhaps related to chronic immune stimulation. Untreated active tuberculosis over a prolonged time period, despite the availability of treatment, is a possible risk factor for NHL.