ABSTRACT
A 92- year-old otherwise healthy female was diagnosed in another institution with thyroid lymphoma on fine needle aspirate [FNA] five years back. The patient repeatedly refused further management. Due to the rapid increase in the size of her tumor, shortness of breath and stridor, she was transferred to our institution and required intubation in the intensive care unit. She had 30x15 cm neck mass extending bilaterally and to the upper chest with an engorged neck and chest veins [Figure 1, A and B; Figure 2A]. Her thyroid-stimulating hormone was 1109 mU/ L [normal range, 0.27 to 4.2 mU/L]. Flow immunophe-notyping from the thyroid FNA specimen confirmed a CD19, CD20, and CD22 expressing monoclonal B-cell population, high forward and side scatter showing surface kappa light chain restriction. CD 10 and CD5 were not co-expressed. These features and morphology were consistent with a large B-cell lymphoma. She received cyclophosphamide 500 mg intravenously and one dose of vincristine 2 mg intravenously and dexamethasone 40 mg intravenously for 5 days. Her tumor was reduced by 70% after five days. Her shortness of breath and stridor increased and chest x-ray showed infiltrates and then aspiration pneumonia [Figure 2B. She developed febrile neutropenia, Klebsiella pneumoni-at bacteremia, deteriorated rapidly, developed multiple organ system failure and died fourteen days after receiving chemotherapy