Pulmonary malignant lymphoma requiring surgical lung biopsy for diagnosis following coronavirus disease 2019 infection: a case report.

BACKGROUND

Pulmonary involvement by peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS), is an exceedingly rare extranodal manifestation with nonspecific radiological and clinical features. Its computed tomography (CT) findings-including ground-glass and consolidative opacities and, in some areas, a crazy-paving appearance-overlap with those of resolving infectious pneumonia and drug-induced lung injury, so that pulmonary lymphoma is readily mistaken for these more common conditions and the diagnosis is often delayed.

CASE DESCRIPTION: A 62-year-old man with a smoking history and stage IIIA classical Hodgkin lymphoma (cHL) treated six years earlier with bleomycin-containing chemotherapy-complicated by resolved grade 1 bleomycin-induced interstitial pneumonia-presented with productive cough and low-grade fever after a mild coronavirus disease 2019 (COVID-19) infection. Chest CT showed diffuse bilateral ground-glass opacities, with areas of a crazy-paving appearance, together with mediastinal and right hilar lymphadenopathy; the soluble interleukin-2 receptor (sIL-2R) level was markedly elevated (1,540 U/mL). Bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) was non-diagnostic, and the patient deteriorated despite broad-spectrum antimicrobial therapy. Video-assisted thoracoscopic surgery (VATS) with wedge resection established the diagnosis of PTCL-NOS, and bone marrow biopsy showed no marrow involvement. Multiple lines of salvage chemotherapy failed to control the disease, and the patient died three months after diagnosis.

CONCLUSIONS

This case underscores the essential diagnostic role of VATS lung biopsy when bronchoscopic investigation fails in patients with treatment-refractory pulmonary infiltrates. The co-occurrence of prior bleomycin exposure and post-COVID-19 pneumonia created overlapping radiological features that delayed diagnosis. PTCL-NOS should be considered in the differential diagnosis of treatment-refractory pulmonary infiltrates-even when nonspecific patterns such as crazy-paving are present-particularly in patients with a prior history of hematologic malignancy and markedly elevated sIL-2R. The temporal onset of disease following COVID-19 infection in this immunologically predisposed patient further raises awareness of a potential association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and lymphomagenesis.