Dilemma in Diagnosing Malignant Pleural Mesothelioma with Atypical Clinical Presentation and Imaging Findings : Recurrent Chylothorax, Mediastinal Lymphadenopathies and Pulmonary Embolism

@#Malignant pleural mesothelioma (MPM) is a rare malignant tumor affecting the mesothelium. It commonly manifests as pleural thickening on contrast enhanced CT (CECT) thorax. We reported a case of a young lady who presented with respiratory symptoms and was initially treated as pneumonia. However, she had recurrent episodes of chylothorax with progressive internal jugular vein (IJV), brachiocephalic vein and superior vena cava (SVC) thrombosis leading to pulmonary embolism, associated with extensive mediastinal and supracalvicular lymphadenopathies. There are no evidence of pleural thickening in the initial investigations. Our case highlighted that MPM must remain in the differential diagnosis for these presentations, albeit rare.

An Atypical Presentation of Tuberculosis Lymphadenitis

ABSTRACT Tuberculosis (TB), one of the oldest diseases of human, remains a global health problem especially in developing countries. Tuberculosis is classified as pulmonary or extrapulmonary. Tuberculosis lymphadenitis is the most common form of extrapulmonary TB. In this report, we present a patient with TB lymphadenitis who had atypical multiple lymph node involvement similar to malignancies without symptoms of lung disease. An 81-year-old male presented with a 3-month history of a growing swelling in the cervical region. In the month prior to presentation another swelling developed in the right axillary region. Physical examination revealed multiple lymphadenopathies in the cervical and axillary regions. A computerized tomography revealed lymphadenopathy at right axillary region 5 × 2 cm in diameter, a cystic mass or abscess at right posterior cervical region 3 × 2 cm in diameter and multiple lymphadenopathies in the cervical regions. Thoracic tomography revealed fibro-atelectasis, thick fibrotic bands and increased reticulonodular density in both lungs which were reported as reactivation of TB. An excisional biopsy was performed which revealed granulomatous inflammatory process with caseous necrosis. Acid-resistant bacteria were detected from microbiological assessment of both the pus of the mass and the nodular lesion via polymerase chain reaction. The diagnosis was reactivated TB lymphadenitis. Although multiple lymphadenopathies accompanied with weight loss suggest malignancies, TB must also be considered in the differential diagnosis.

Leucemia/linfoma T del adulto tipo linfomatoso por HTLV-1 en una mujer joven / Adult T cell lymphoblastic leukemia/lymphoma by HTLV-1 in a young woman

Resumen La leucemia/linfoma T del adulto (LLTA) de tipo linfomatoso es un subtipo del linfoma de las células T, causado por la infección del virus linfotrópico de células T humanas tipo 1 (HTLV-1); el cual genera una integración proviral en el ADN del hospedero y expansión clonal de linfocitos T. Presentamos el caso de una mujer de 20 años que desarrolló linfadenopatías múltiples, hepatoesplenomegalia y fiebre, con serología positiva para HTLV-1 y reacción de polimerasa en cadena (RPC) con la integración proviral en el ADN del hospedero. La inmunohistoquímica en un ganglio linfático fue positiva para células T CD4+ y CD8+. La LLTA ha sido descrito en todas las áreas endémicas del HTLV-1; sin embargo, existen diferencias en la edad de presentación según la región: 40 a 50 años en América del Sur y 60 años en Japón. Presentamos uno de los pocos casos reportados de LLTA de tipo linfomatoso en adultos jóvenes.

Adult T cell lymphocyte leukemia/lymphoma (ATLL) is a subtype of T-cell lymphoma caused by infection of the human T-cell lymphotropic virus type 1 (HTLV-1); which generates a pro-viral integration into the host DNA, resulting in a clonal expansion of T lymphocytes. We present the case of a 20-year-old woman who developed multiple lymphadenopathies, hepatosplenomegaly and fever, serum positivity for HTLV-1 and proviral integration in the host DNA, demonstrated by polymerase chain reaction (PCR). Immunohistochemistry of lymphoid node was positive to CD4+ and CD8+ T cells. ATLL has been described in all HTLV-1 endemic areas, however, there are differences in the mean age of its presentation in such areas: 40 to 50 years in South America, 60 years in Japan. We showed one of few reported cases of the lymphoma type of ATLL in young adults.

Brucellosis: A lymphoma-like presentation

Brucellosis is one of the most common zoonotic infections worldwide caused by gram negative bacilli of the genus Brucella. It is transmitted to humans by contact with infected animals or derived food products such as unpasteurized milk. Brucellosis' clinical presentation varies widely from multi-systemic involvement to asymptomatic infection. We present the case of a 52-year-old Lebanese male who was admitted to our hospital with a 3-week history of fever (up to 40 °C), chills, night sweats and abdominal pain. Abdominal CT scan revealed the presence of several mesenteric lymphadenopathies and some retroperitoneal lymphadenopathies. Blood cultures came back positive for Brucella melitensis, and a follow-up CT of the abdomen done after treatment revealed complete resolution of the lymphadenopathies. To our knowledge, this is the first case in the literature of brucellosis presenting as retroperitoneal and mesenteric lymphadenopathies. In endemic areas, the diagnosis of brucellosis should always be raised in front of any long duration fever even in the absence of a typical clinical presentation.

Brucellosis: A lymphoma-like presentation

Brucellosis is one of the most common zoonotic infections worldwide caused by gram negative bacilli of the genus Brucella. It is transmitted to humans by contact with infected animals or derived food products such as unpasteurized milk. Brucellosis' clinical presentation varies widely from multi-systemic involvement to asymptomatic infection. We present the case of a 52-year-old Lebanese male who was admitted to our hospital with a 3-week history of fever (up to 40 °C), chills, night sweats and abdominal pain. Abdominal CT scan revealed the presence of several mesenteric lymphadenopathies and some retroperitoneal lymphadenopathies. Blood cultures came back positive for Brucella melitensis, and a follow-up CT of the abdomen done after treatment revealed complete resolution of the lymphadenopathies. To our knowledge, this is the first case in the literature of brucellosis presenting as retroperitoneal and mesenteric lymphadenopathies. In endemic areas, the diagnosis of brucellosis should always be raised in front of any long duration fever even in the absence of a typical clinical presentation.

Melanoma metastásico con tumor primario oculto / Metastatic melanoma with occult primary tumor

In 3 percent of melanomas, the primary tumor is occult. We report a 58 years old female presenting with rapidly growing painless left inguinal lymphadenopathies. The patient was reassessed two months later, verifying that the lesions enlarged further. A CAT scan of the left inguinal region showed a solid mass in the subcutaneous of the proximal region of the left thigh. An incisional biopsy of the inguinal mass was performed. The pathological study disclosed malignant melanoma. The patient was subjected to an iliofemoral lymphatic excision and to five sessions of regional radiotherapy. After two years of follow up, the patient is without evidence of tumor recurrence.

En el 3 por ciento de los melanomas, el tumor primario está oculto. Reportamos una mujer de 58 años, que presentaba linfadenopatías inguinales dolorosas. Reevaluada dos meses después, se constató crecimiento de la masa. Una TAC motró una masa sólida subcutánea en zona proximal de muslo izquierdo, la que fue biopsiada, demostrándose un melanoma. Se realizó disección linfática ilofemoral y cinco sesiones de radioterapia. A los dos años, la paciente no evidencia recurrencia tumoral.

Kimura's Disease Involving Thoracic and Abdominal Lymph Nodes in a Hemodialysis Patient

We report the first observed case of Kimura's disease occurring during hemodialysis, involving the thoracic and abdominal lymph nodes, which spontaneously resolved nearly completely after two months. Early diagnosis and recognition of Kimura's disease may spare both the patient and doctor from the need for unnecessary invasive diagnostic procedures. Therefore, we emphasize that we need to have a high index of suspicion regarding Kimura's disease.