Presentation
Febrile fever for a week, fatigue, pancytopenia. Finished chemotherapy for non-Hodgkin gastric lymphoma (mantle cell type) 2 months ago.
Patient Data
Multiple bilateral areas of ground glass opacities with intralobular interstitial thickening.
Lesions predominantly peripheral distribution.
Mild interlobular reticular pattern in basal lung zones.
Additional clinical note: Patient had COVID 19 positive PCR, so she started to receive therapy according to the national guidelines including tocilizumab (IL-6 inhibitor). Clinically only mild improvement has been seen.
Chest CT 2 weeks later:
Diffuse interlobular interstitium thickening.
Inhomogeneous pneumatization of both lungs.
Area of ground glass opacity in S8-10 of the left lung transformed into crazy-paving pattern, without changes in size.
Case Discussion
Since the patient has a history of gastric non-Hodgkin lymphoma (mantle cell type) transbronchial biopsy was performed. It revealed signs of lymphagitic carcinomatosis of mantle cell lymphoma (anaplastic variant).
Location of primary tumor in stomach relatively commonly associated with pulmonary lymphagitic carcinomatosis1,2. Precise spectrum of risk factors is unknown, but in this case dramatic progression of the disease might be caused by using of immunosuppressive therapy (tocilizumab) and pathologic impact of the novel coronavirus (SARS CoV-2) itself.
Although no specific findings for lymphagitic carcinomatosis3,4, a high index of suspicion is required in any patient with a new lung abnormality, especially diffuse, and known non-Hodgkin lymphoma in the anamnesis1-4.