Non-Hodgkins lymphoma in a patient with tracheal bronchus who presented with atypical pneumonia: a diagnostic dilemma.

DESCRIPTION A 47-year-old unemployed man presented with a 2-week history of shortness of breath, dry cough and fever despite normal inflammatory markers and negative blood cultures. There was no weight loss or night sweats. He was a non-smoker and had no other medical history. HIV testing and tumour markers were negative. Chest x-ray (figure 1A) showed what seemed to be a dense consolidation in the right mid-zone and lower zone. This was confirmed on CT (figure 1F), so wedge biopsies of the right middle and right lower lobes were taken via video-assisted thoracoscopy (VATS). There were no palpable lymph nodes and no evidence of significant mediastinal lyphadenopathy on CT (figure 1C–E). Bronchoscopy at the time of VATS showed a tracheal (pig) bronchus with the right upper lobe bronchus arising separately from the trachea (figure 1B). Postoperative course was uneventful and he was discharged in good health to the respiratory physicians on day 3. There was no definitive diagnosis following histopathological examination of the lung biopsies. Cultures of the biopsies were negative for any pathogens. With no definite diagnosis, he received nebulisers and oxygen in the interim but subsequently developed seizures requiring intubation and ventilation. MRI, at this time, showed lesions in the brain and he continued to deteriorate and eventually passed away. Postmortem examination showed high-grade nonHodgkins lymphoma—B-cell type predominantly affecting the brain but also infiltrating the lungs, heart, liver, kidneys and urinary bladder (figure 2). Learning points