SHM Converge Scientific Abstract ePoster Gallery-Lymphomatoid Granulomatosis Masquerading as Septic Emboli: A Case Report

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This case report describes a 72-year-old man with two months of fever, night sweats, malaise, and dyspnea after recent dental work. An initial infectious and cardiac evaluation was unrevealing, but chest CT showed bilateral pulmonary nodules and PET imaging demonstrated lung nodules with cervical, mediastinal, and hilar lymphadenopathy. Fine-needle aspiration of lymph nodes was negative for malignancy, and he was initially treated as having right-sided infective endocarditis with septic emboli using ceftriaxone and doxycycline for six weeks. His fever improved and lung nodules decreased, but he returned two weeks later with recurrent fevers, worsening dyspnea, and new cervical lymphadenopathy.<br /><br />Repeat imaging showed progressive thoracic and abdominal lymphadenopathy, splenomegaly, and pleural effusions. Excisional biopsy of a cervical lymph node revealed atypical medium-to-large lymphoid cells with prominent nucleoli in a mixed inflammatory background. Immunohistochemistry showed CD3-positive atypical cells with MUM1, CD45, and EBER-ISH positivity, supporting a diagnosis of stage IIIB lymphomatoid granulomatosis (LYG), based on the initial pulmonary nodules.<br /><br />LYG is a rare EBV-driven B-cell lymphoproliferative disorder that typically involves the lungs and can present with constitutional symptoms and variable extra-pulmonary disease, making diagnosis difficult. In this case, the apparent improvement in lung nodules may have reflected spontaneous regression rather than antibiotic response. The patient was treated with R-DA-EPOCH for one cycle and then switched to R-CHOP, with resolution of symptoms and lymphadenopathy.<br /><br />The report emphasizes that LYG should be considered in patients with unexplained febrile illness and pulmonary nodules, even when an infectious workup is negative.

Asset Subtitle

Jason D. Lofters

Meta Tag

Author List Angelica Medina-Pena, Jason D. Lofters, Joseph Fleischer, Maxwell Janosky, Ro-Kaye Simmonds, Ross Lavine, Sofia Terner, Zachary Banbury

Category Clinical Vignettes

Concept Lymphomatoid Granulomatosis

Concept Epstein-Barr Virus

Concept Pulmonary Nodules

Concept Tissue Diagnosis

Concept B-Cell Lymphoproliferative Disorder

Distinguished Non-Finalist

Presenter Organization Englewood Hospital

Presenting Author Jason D. Lofters

Track Adult

Keywords

lymphomatoid granulomatosis

EBV-driven lymphoproliferative disorder

pulmonary nodules

fever of unknown origin

mediastinal lymphadenopathy

cervical lymphadenopathy

splenomegaly

infective endocarditis mimic

R-DA-EPOCH

R-CHOP

Lymphomatoid Granulomatosis

Epstein-Barr Virus

Pulmonary Nodules

Tissue Diagnosis

B-Cell Lymphoproliferative Disorder