A 72-year-old woman with a history of smoking (50 pack-years), alcoholism and extrinsic asthma presented with fever, cough and increased dyspnea.
On physical examination, the patient presented with a febricula (37.9o C), tachypnea and hypoventilation with sedatives.
No visceromegaly or lymphadenopathy were observed.
Laboratory tests showed mild neutrophilia and mild thrombocytopenia, and Gram and Ziehl-Neelsen stain were negative.
The chest X-ray showed left paracardiac condensation with air bronchogram, which erased the cardiac silhouette and the computerized axial tomography (CAT) confirmed the existence of a left pulmonary infiltrate, with pulmonary involvement.
With the suspected diagnosis of bronchodilator pneumonia, treatment was initiated with bronchodilators, antibiotic therapy and amoxicillin-clavulanic acid, with clinical improvement and disappearance of the fever.
The patient was discharged for follow-up in the pulmonology department where, due to the persistence of the condensation image, the patient was studied.
Bronchoscopy showed nonspecific inflammatory signs in the left bronchial tree with normal right; cytology of aspirate and bronchial brushing was negative for malignancy.
CT-guided needle aspiration (FNAC) revealed a monomorphic lymphoid proliferation consistent with non-Hodgkin lymphoma (NHL).
A lung biopsy by minithoracotomy confirmed the diagnosis of small cell lymphocytic lymphoma B (small cell lymphoma) CD 20 positive, bcl-2 positive, and p-53 negative.
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Biological studies showed a slight increase in ESR, b2-microglobulin and the presence of a IgM lambda minimonoclonal band in the proteinogram.
Viral serology and autoimmunity study (ANOES) were negative.
Abdominal ultrasound showed incipient signs of diffuse chronic liver disease and abdominal CT showed no lymphadenopathy.
A new chest CT scan confirmed the presence of a dense, homogeneous, 5x7 cm lung mass, with a fixed-form pattern on the basis of apex, pericardium, upper mediastinum, and chest wall deviation.
Bone biopsy ruled out lymphoma.
With the diagnosis of low grade primary pulmonary lymphoma (PPL), oral treatment was initiated with chlorambucil pulses, 40 mg orally day 1, and prednisone, 100 mg/day for 4 days, every 4 weeks.
In the first reassessment, after four cycles of chemotherapy, the size of the tumor mass had not changed, so the patient was proposed treatment with intravenous polychemotherapy that he rejected.
Continuous chlorambucil was then started at a dose of 3 mg/day.
A new chest CT scan showed a decrease in lung mass diameter greater than 50% (8 months later) and greater than 75% (16 months after starting daily treatment).
As side effects presented liver toxicity, both WHO grade I, so the dose of chlorambucil was reduced to 1 mg/day.
After two years of continuous treatment, chest X-rays and CT scans showed pulmonary well defined parenchymas, and only a residual fibrous tract was observed in the left lung.
A gallium-67 scintigraphy showed hyperactivity at the middle third of the left hemithorax, thus confirming the existence of residual disease.
Despite this, the patient has maintained therapeutic abstention, in very good partial remission (MBRP) and progression-free survival to date (progression-free interval of 53 months).
