Acute Encephalopathy and Cardiac Tamponade as Initial Presentations of High-Grade B-Cell Lymphoma

Figures

• 

  Figure 1. Computed tomography angiography (CTA) demonstrating incidental cardiopulmonary findings. The upper arrow indicates a large pericardial effusion, while the lower arrows indicate bilateral pleural effusions, greater on the right. CTA showed no large-vessel occlusion or hemodynamically significant stenosis. The pericardial effusion was incompletely imaged on this examination.

• 

  Figure 2. Transthoracic echocardiogram demonstrating a large pericardial effusion. Global left ventricular ejection fraction was approximately 55%. Diastology was indeterminate. Right ventricular cavity size appeared moderately dilated. Transthoracic echocardiography demonstrated a large circumferential pericardial effusion. Parasternal short-axis views (A-C) showed extensive pericardial fluid surrounding the left ventricle. Apical four-chamber views (D-F) confirmed the large circumferential effusion and demonstrated moderate right ventricular dilatation. Left ventricular size and systolic function were preserved, with an estimated ejection fraction of approximately 55% and no regional wall motion abnormalities. The inferior vena cava was dilated with less than 50% inspiratory collapse, and significant respiratory variation was present. Although these findings raised concern for evolving tamponade physiology, there was no echocardiographic evidence of right atrial or right ventricular collapse. A large pleural effusion was also noted.

• 

  Figure 3. Computed tomography angiography (CTA) of the chest obtained after pericardiocentesis. The upper arrow indicates a residual moderate pericardial effusion. The central arrow indicates the pericardial drain in situ. The lower right and lower left arrows indicate persistent bilateral pleural effusions, including a moderate right pleural effusion and a small left pleural effusion, with associated partial collapse of the right and left lower lobes. Despite interval drainage, residual pericardial and pleural fluid collections remained. Underlying malignancy could not be excluded.

• 

  Figure 4. Cytologic analysis of pericardial and pleural fluid specimens demonstrating involvement by high-grade B-cell lymphoma. (A) Pericardial effusion cytology (May-Grünwald-Giemsa stain) demonstrating large atypical lymphoid cells with enlarged nuclei, vesicular chromatin, prominent nucleoli, and abundant cytoplasm in a background of reactive lymphocytes. (B) Pleural effusion cytology (Papanicolaou stain) showing scattered large neoplastic lymphoid cells with high nuclear-to-cytoplasmic ratios and conspicuous nucleoli. (C) Hematoxylin and eosin (H&E)-stained cell-block section demonstrating diffuse infiltration by large atypical lymphoid cells. (D) Higher-magnification H&E image highlighting marked nuclear pleomorphism, vesicular chromatin, and prominent nucleoli characteristic of aggressive B-cell lymphoma. (E) PAX5 immunohistochemistry showing strong nuclear staining in neoplastic cells, confirming B-cell lineage. (F) CD20 immunohistochemistry demonstrating membranous expression in the tumor cells. (G) BCL6 immunohistochemistry showing nuclear positivity. (H) MUM1 immunohistochemistry demonstrating nuclear expression consistent with an activated B-cell phenotype. (I) Ki-67…