Female patient, 59 years old, hypertensive.
CABPD patient in adolescence, treated.
History of 8 months of fever up to 39 °C and cough.
It was managed with different antimicrobial schemes without response.
She was initially admitted to another hospital where a computed tomography (CT) of the chest showed massive opacities in the left lower lobe and multiple bilateral cavitated pulmonary nodules.
The HIV test was negative.
Susceptible bacilli (BK) and expectoration Koch cultures were negative.
Bronchoalveolar lavage (BAL) and biopsy were performed, and a transbronchial histological study revealed a chronic granulomatous inflammatory process, without leukocytes, with negative Ziehl-Nielsen staining.
Aerobic current culture, BK and Koch culture were negative.
Polymerase chain reaction (PCR) for M. tuberculosis was also performed with the commercial kit AMPLICOR® (Roche Diagnostics System, USA), whose result was positive ministerial TB, probably due to a relapse.
Despite this, the patient persisted with marked compromise of the general state, remained febrile and with progressive weight loss of 20 kg in the following 3 months.
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Given this poor outcome, the patient was hospitalized in the Hospital del Salvador for study.
A new FBC was performed with transbronchial biopsy, which showed diffuse large cells with lymphoid appearance.
However, immunohistochemistry (IHC) failed to confirm lymphoma.
Microbiological study bacterial, fungal and mycobacterial was again negative.
The patient remained febrile and with progression of the pulmonary masses evidenced in a new chest CT.
A new biopsy was performed, this time surgical by videothorac.
The histological sample and the IHC showed a lung with reactive lymphoid infiltrate.
The patient developed cervical and inguinal lymphadenopathies of 2 cm in one month, not adhered to deep planes, neither fistulized nor painful.
Biopsy of an inguinal adenopathy was performed, which finally confirmed an anaplastic GDCGB NHL by IHC (positive for CD20, BCL-2, CD30).
Antituberculosis therapy was suspended, being in the second week of the biweekly phase.
Chest, abdomen and pelvis CT showed multiple mediastinal, axillary, retroperitoneal, infracavo-aortic lymph nodes and multiple iliac chains enlarged more than 3 cm.
OM biopsy showed high cellularity, with non-necrotic multinucleated giant cell granulomas.
No lymphoid process was found, nor did neoplasic infection with immunohistochemistry and Ziehl-Nielsen stain were negative.
Again, questions were raised about the role of disseminated tuberculosis infection as a concomitant diagnosis.
BK, culture of Koch and PCRLICOR®M. tuberculosis in MO were performed, which were negative.
The case was evaluated by a multidisciplinary team, and a definitive diagnosis of lymphoma with pulmonary involvement and sarcoid reaction in OM is proposed together.
It was proposed that positive PCR for M. tuberculosis of BAL fluid is a non-viable strain in the context of an old infection.
Chemotherapy with rituximab, cyclophosphamide, vincristine, doxorubicin and prednisone (R-CHOP) was started with very good response.
Six cycles were administered, achieving complete remission (CR) of the disease.
Currently, the patient is under control, remaining in CR for 5 years.
