A Case of Human Herpes Virus-8 Unrelated Primary Effusion Lymphoma-Like Lymphoma Presented as Pleural Effusion
An 80-year-old Korean woman was admitted to our hospital on April 13, 2009, complaining of experiencing exertional dyspnea, cough, and sputum production in the past two weeks. She had been treated for hypertension three years ago, and family history was non specific.\nPhysical examination revealed that breath sounds on the left lower hemithorax were decreased. The liver, spleen, and superficial lymph nodes were not palpable. Hemogram revealed a leukocyte of 6,000/mm3, a hemoglobin of 12.2 g/dL and a platelet count of 224,000/mm3. The blood chemistry profile showed the following: total protein level 7.6 g/dL, albumin 2.9 g/dL, total bilirubin 0.41 mg/dL, aspartate aminotransferase 21 IU/L, alanine aminotransferase 13 IU/L, alkaline phosphatase 309 IU/L, lactate dehydrogenase (LDH) 377 IU/L, blood urea nitrogen 12.1 mg/dL, and creatinine 0.7 mg/dL. Chest X-ray and computed tomography of chest revealed left pleural effusion (). The analysis of left pleural fluid revealed the following: pH 8.0, protein 5.8 g/dL, and LDH 12,580 IU/dL. Cell count of the pleural fluid showed a leukocyte of 3,400/mm3 (77% lymphocytes). Pleural fluid adenosine deaminase (ADA) was 131 IU/L. Cytological evaluation of the pleural fluid indicated that no malignant cells were present. She was diagnosed with tuberculous pleural effusion, and first-line anti-tuberculous drugs were administered. Three months after taking anti-tuberculous drugs, the volume of pleural effusion increased again. Thoracentesis and pleural biopsy were performed. It showed lymphocyte-dominant exudate. Pleural fluid ADA was 88 IU/L. Cytological evaluation of the pleural fluid indicated many lymphoid cells were seen and no malignant cells were present. Pleural biopsy also showed no malignant cells. She was diagnosed for paradoxical response after the treatment of tuberculosis. Therefore, anti-tuberculous drugs were administered continuously.\nSix months after the initial administration of anti-tuberculous drugs, the volume of pleural effusion increased again. Thorough analysis of the pleural fluid followed. The analysis of left pleural fluid revealed the following: pH 7.5, protein 3.1 g/dL, and LDH 7,460 IU/dL. Cell count of the pleural fluid showed a leukocyte of 12,750/mm3. Pleural fluid ADA was 52 IU/L. Cytological evaluation of the pleural fluid showed many atypical lymphoid cells having medium to large nuclei and nucleoli. This suggested B lymphoid cell malignancy is possible. So we performed positron emission tomography-computed tomography scan. It showed strong fluorodeoxyglucose uptake in the mediastinal pleura (). Histological tests were performed on the mediastinal pleura and adjacent tissues by mediastinoscopy. The biopsy finding of the pleura revealed the infiltration of atypical cells to fibrotic tissues (). These cells were positive for CD20 and bcl-2, but negative for CD3, CD5, CD21, CD30, CD138, and epithelial membrane antigen (EMA). The cells also showed high Ki-67 (60~70%) (). The tests for HHV-8 in the tissue were negative.\nFinally, she was diagnosed as HHV-8 unrelated primary effusion lymphoma-like lymphoma. In serological tests, HIV, hepatitis C virus (HCV), and EBV-polymerase chain reaction (EBV-PCR) were negative. Considering her old age, further treatments were not performed. She has shown good prognosis despite receiving no chemotherapy for more than 18 months ().