52 Years old HIV positive male with Chest Pain

Modality: X-ray

CXR at presentation, 2 weeks, 3 weeks and 4 weeks. Large right opacity showing rapid progression over 4 weeks.

PET/CT at the time of presentation.

Modality: Nuclear medicine

Large right pleurally based mass, with partial necrosis, and a number of smaller satellite pleurally based nodules.

CT 4 weeks after presentation.

Modality: CT

The right pleurally based mass has grown to a huge necrotic mass occupying the whole of the right chest and causing diaphragmatic eversion. Marked displacement of the mediastinum and heart to the left.

Right pleural mass core biopsy (performed at time of presentation)
Microscopic description: Tissue shows blood clot and cells which are large, pleomorphic and show prominent eosinophilic nucleoli. Cells show a nuclear Hof and a lightly basophilic cell cytoplasm with eccentric cell nuclei. The cells are immunoreactive with CD138 and show some weak immunoreactivity with CD45 but no reactivity with CD20, CD3, PAX5, CD30, BCL6 or EMA.

Diagnosis: Core biopsies show features of a high grade lymphoma most in keeping with a plasmablastic lymphoma.

Case Discussion:

Primary pleural lymphomas are rare. More commonly, pleural involvement is seen in non-Hodgkin's lymphoma as secondary pleural effusions or thickening.

Two types of primary pleural lymphomas are described in the literature: in HIV positive patients (as in this case), and associated with pyothorax in patients with tuberculosis.

Sadly, the patient did not survive this admission.