Our patient was a 22-year-old man with no significant personal history who consulted for dyspnea on moderate exertion and recent onset of left pleuritic pain. Bilateral axillary, supraclavicular and inguinal lymphadenopathies were observed on physical examination. Chest radiograph (Fig. 1A) showed massive left pleural effusion and an anterior mediastinal mass. Given these findings, the study was expanded with positron emission tomography (PET-CT) that revealed nodal, pleural and renal involvement, supporting our suspicion of a lymphoproliferative process (Fig. 1B, C).
(A) Chest X-ray image showing unilateral white hemithorax associated with massive pleural effusion causing contralateral displacement and an anterior mediastinal mass. (B, C) PET-CT: Large heterogeneous lymph node cluster in prevascular mediastinal fatty space, with areas of hypometabolism and necrosis and other hypermetabolic regions consistent with malignancy, displacing mediastinal structures to the right and engulfing the large vessels. Significant for marked left pleuropulmonary thickening, measuring up to 6cm in the paracardiac region, with intense pathological metabolic activity.
A pleuropulmonary ultrasound revealed significant pleural thickening, ruling out the possibility of diagnostic thoracentesis. We decided, therefore, to perform fine-needle aspiration and biopsy of an axillary adenopathy. Results showed T-cell lymphoblastic lymphoma that was confirmed in a subsequent core-needle biopsy of the mediastinal mass.
T-cell lymphoblastic lymphoma is an aggressive form of non-Hodgkin lymphoma that, as in our case, occurs in adolescent men and accounts for 1% of all non-Hodgkin lymphomas.1 Cases such as this have been described in the literature, but few have involved such a dramatic presentation.
It is important to highlight the need for this entity to be included in the differential diagnosis of pleural effusion, because its therapeutic management is completely different and early diagnosis is important for the prompt initiation of chemotherapy.2
FundingThe authors declare that they have no funding.
Conflict of interestsThe authors state that they have no conflict of interests.
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