A 75-year-old man presented with multiple neck swellings for 4 years and breathing difficulties associated with a productive cough and yellowish sputum for 2 weeks. He reported a history of receiving pulmonary tuberculosis (TB) treatment more than three times in his life. He also reported that his brother suffered similar problem and possibly died of respiratory complications from numerous neck swellings.
On physical examination, the patient was alert, had finger clubbing, and had several mobile, firm, unmated lymph nodes in the submandibular (Figure 1), cervical, supraclavicular, axillary, and inguinal regions. Hepatomegaly, bilateral basal crepitation, respiratory rate of 24 breaths per minute, and saturation of 93% on 4 L of oxygen were also noted. Examination of other systems was essential unremarkable.
A computed tomography (CT) scan of the chest and abdomen revealed bilateral axillary, mediastinal, hilar, and cervical lymphadenopathy. Left lower lobe consolidation, right apical and basal consolidation, a moderate pleural effusion on the left paraaortic, mesenteric, iliac, and inguinal lymph node enlargement with calcification in the center were evident (Figure 2). Gene Xpert for TB and HIV testing results came back negative, routine blood parameters were within normal limits. Diagnosis of malignant lymphoma was entertained. Histopathology of excisional biopsy from one of the neck mass revealed mantle zones thickening with lymphocytes arranged in layers giving the appearance of skin onion skin (Figure 3(a)-(b)). In addition, the cell did not express human herpesvirus-8 (HHV-8) immunoreactivity. However, the concentric rings of follicular cells were positive for CD21 while the germinal centers cells demonstrated CD10 immunopositivity. The diagnosis of idiopathic MCD with supplemental bacterial pneumonia was suggested and the patient was kept on chemotherapy (Rituximab) as well as antibiotics (Ceftriaxone and Azithromycin) and steroids (Hydrocortisone). He improved remarkably and has been symptoms free for 1 year of follow-up.