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Nonresolving Pneumonia*
A 57-year-old man presented to a local hospital with right-sided pleuritic chest pain. The patient denied fever, cough, and weight loss or other constitutional symptoms. His medical history was significant for hypertension, type 2 diabetes mellitus, and hypercholesterolemia. He had no allergies, and his medications included gemfibrozil, ranitidine, amlodipine, and glyburide. Physical examination disclosed no abnormalities. A chest radiograph showed a dense right middle lobe infiltrate. Pneumonia was diagnosed, and antibiotic treatment, including a second-generation cephalosporin and a macrolide, was administered. After 2 weeks of antibiotic therapy, the chest roentgenogram remained unchanged. Bronchoscopy with bronchial brushings, BAL, and transbronchial biopsies of the right middle lobe were nondiagnostic, revealing only fragments of lymphoid tissue and inflammatory fibrinous material. All cultures were negative for bacterial organisms.
The patient was incarcerated, and 10 months after the initial evaluation, he presented to the Medical College of Virginia where a subsequent chest radiograph was unchanged (Fig 1). A CT scan of the chest confirmed the presence of a dense right lower lobe infiltrate with air bronchograms, extending into the superior segment of the right lower lobe (Fig 2). Another bronchoscopy with transbronchial biopsy revealed a lymphocytic infiltrate with presence of both B and T lymphocytes. Immunoperoxidase studies showed a predominance of B lymphocytes (CD20+) with scattered T lymphocytes also present (CD3 and CD43+). Staining for kappa and lambda proteins was inconclusive. Thus, although marker studies showed a predominance of B lymphocytes, clonality was not established. This finding was suggestive of a reactive process rather than of a lowgrade lymphoproliferative disorder. An intermediate strength PPD skin test was nonreactive with positive controls. An HIV test was negative and serum chemistry values as well as hematologic studies were within normal limits. An inguinal node measuring 2.3 x 2 x 1 cm was excised and found to be normal after histologic and immunochemical evaluation. A few months later, the patient returned for a follow-up examination and reported persistent right-- sided chest discomfort. Another bronchoscopy with molecular diagnostic techniques applied to the specimens obtained by BAL and transbronchial biopsy was performed.
What is the diagnosis?
Diagnosis: Primary pulmonary non-Hodgkin's lymphoma, small cell, B lymphocyte type
When lobar consolidation is diagnosed on the basis of a conventional chest...