Miliary Nodules in a Young Adult: A Rare Pulmonary Manifestation of B-cell Lymphoma

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Abstract Introduction: “Miliary nodules” refer to a radiographic finding of innumerable uniformly diffuse and randomly spaced pulmonary nodules. The differential includes infections such as fungal and tuberculous, malignant metastases most commonly from solid malignancies such as non-small cell lung cancer, breast cancer, and gastrointestinal cancers, as well as other causes such as sarcoidosis, pneumoconiosis, hypersensitivity pneumonitis, and pulmonary hemosiderosis. Most commonly are the infectious causes, and the workup of miliary nodules typically involves the exclusion of these. Described here is a rare manifestation of a liquid tumor presenting as miliary pulmonary nodules. Case Presentation: A 19-year-old male presented with a two-day history of fevers and thoracic back pain. His CT chest showed bilateral and innumerable diffuse, tiny, randomly distributed pulmonary nodules. Infectious workup including sputum cultures, respiratory viral panel, urine histoplasma antigen, serum cryptococcal antigen, fungal serology panel, Strongyloides antibody, tuberculosis immunoglobulin release assay, sputum acid-fast bacillus smear, sputum Mycobacterium tuberculosis complex polymerase chain reaction, and blood cultures, revealed no evidence of infection. A CT-guided core biopsy of supraumbilical anterior omental nodules and caking revealed a CD-10+ high grade B-cell lymphoma with features of Burkitt Lymphoma. By immunohistochemistry, the lymphoma cells were diffusely positive for CD10, CD20, PAX5, c-MYC, BCL2, and BCL6. He underwent chemotherapy treatment with DA-R-EPOCH, which includes rituximab, etoposide, cyclophosphamide, doxorubicin, intrathecal methotrexate, and prednisone. Follow-up nuclear PET CT scan three months later showed resolution of the nodules. Given the exclusion of infectious organisms and resolution with chemotherapy, the miliary nodules were attributed to lymphoma. Discussion: Lymphomas uncommonly present with pulmonary manifestations, and when they do, are typically due to metastatic (secondary) pulmonary involvement rather than a primary pulmonary lymphoma. Radiographically, metastatic lymphomas classically present as pulmonary nodules, masses, consolidations, and ground-glass opacities. In cases of nodules, they can be bilateral and many in number, but there have been only a few case reports as miliary nodules, and of those, tend to favor an older population. One case involved a 67-year-old male presenting with diffuse large B cell lymphoma. Another presented a 60-year-old male with non-Hodgkin's lymphoma. The third case described an 80-year-old with lymphoma, of which the subtype was not specified. Given the paucity of cases with such findings, this case should make clinicians consider lymphoma in the differential of miliary nodules in cases of young adults presenting with systemic symptoms, miliary lung nodules, and no identifiable infectious etiologies.

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