Holy Cyst! Solitary Pulmonary Cystic Mass Presenting as Diffuse Large B Cell Lymphoma

Diffuse large B -cell lymphoma (DLBCL) represents the most common subtype of non -Hodgkin lymphoma 1 , characterized by its aggressive clinical course and heterogeneity. Although approximately 40% 2 of Diffuse large B -cell lymphoma have secondary lung involvement, the uniqueness of this case is the radiographic presentation and the lung as its primary site of origin. An 82 -year -old male with a history of recurrent Deep vein thrombosis (DVT), essential tremors, and benign prostatic hyperplasia (BPH) who is currently on long -term anticoagulation therapy presented with complaints of progressive weakness, cough, and shortness of breath for one month. He also reported an associated 20 lbs. weight loss in the past six months. His review of systems was negative. Physical examination findings revealed mildly decreased breath sound to the right apex. His laboratory results were non -contributory and showed negative echinococcus and HIV serology. Chest x -ray revealed a large lesion with heterogeneous attenuation 8.8 x 9.0 x 9.3 cm centered within the right apical lung zone with no apparent invasive component into the mediastinum or soft tissue spaces of the neck. This was followed by a non -contrast Computed tomography (CT) of the chest, which showed a heterogeneous fatty attenuation lesion with significant mediastinal and axillary lymphadenopathy measuring 1.3 cm. Given the CT findings and otherwise negative work -up, two weeks after the initial CT, the patient received Computed tomography of the chest, abdomen, and pelvis (CT CAP) showing necrotic appearing mediastinal, axillary and supraclavicular lymph nodes enlarged compared to the previous scan with thick internal septations and debris within the cyst. He subsequently had an Ultrasound -guided lymph node biopsy with histopathology revealing a diffuse infiltrate of large B -cell lymphoma cells. The patient refused any further intervention or chemotherapy and was discharged. He was later readmitted and treated for aspiration pneumonitis and subsequently placed on hospice care as per his request.