Nodules and gastrointestinal perforation secondary to Epstein–Barr virus-associated lymphoproliferative disease

RATIONALE Non-resolving pneumonia and pulmonary nodules have a broad differential diagnosis and can present a significant diagnostic challenge. We describe a rare etiology and presentation of pulmonary nodules in a previously healthy patient.CASE PRESENTATION A 31-year-old patient visiting from Japan was admitted to the general surgery service with a bowel perforation of unclear etiology. Incidentally, abdominal imaging revealed extensive bilateral pulmonary nodules and pleural effusions. Despite treatment with broad-spectrum antibiotics, the patient remained persistently hypoxemic with ongoing fevers and chills.INVESTIGATIONS Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy, followed by transthoracic biopsy of pulmonary nodules, were inconclusive due to extensive tissue necrosis. Epstein–Barr virus (EBV) serology and viral load were subsequently found to be markedly elevated. A secondary hematopathology review of the resected bowel specimen, along with repeat bronchoscopy, ultimately established the diagnosis of chronic active EBV infection (CAEBV), which was later revised to extranodal NK/T-cell lymphoma (ENKTL).CONCLUSION EBV is a ubiquitous infection that is rarely associated with lymphoproliferative disorders such as CAEBV infection and ENKTL. These conditions often present with nonspecific features, including infectious mononucleosis-like symptoms, and only rarely involve the lungs or gastrointestinal tract. To our knowledge, this is the first reported case of ENKTL presenting with both gastrointestinal perforation and bilateral pulmonary nodules.