Acute Large B-Cell Lymphoma

A 68-year-old man presented with diplopia, progressive dyspnea, leg swelling, weakness, night sweats, and a 9-kg (20-lb) weight loss. He had been healthy up until 2 weeks earlier, when the symptoms started. The patient's medical, social, and family history was noncontributory.

Wael A. AlJaroudi, MD, of Duke University Medical Center, Durham, NC, reports that the patient had left sixth nerve palsy, a normal thyroid gland, a palpable epigastric mass, and no testicular masses. An MRI scan of the brain showed no evidence of stroke or tumor. An electromyogram was negative for myasthenia gravis.

A chest film revealed a mediastinal mass (A, arrow). A CT scan of the chest showed a mass (7.2 3 4.8 cm) that eroded into the anterior right ventricle and likely involved the pericardium and that invaded the posterior aspect of the right atrium (B, arrow).Results ofa tissue biopsy revealed acute large B-cell lymphoma.

The differential diagnosis of anterior mediastinal mass includes the "4 Ts," better known as:

• Thymoma.

• Teratoma (germ cell tumors).

• Thyroid cancer (also parathyroid adenomas).

• "Terrible" lymphoma, as in this patient.

Less common causes include connective tissue tumors, such as lipomas, liposarcomas, and sarcomas.

A lumbar puncture to rule out CNS involvement was planned, and an aggressive chemotherapy regimen was scheduled. However, 3 days later, cardiac arrest developed, and the patient died.