Non-Hodgkin's lymphoma presenting with pulmonary involvement

A 25-year-old woman presented with a history of episodes of fever with night sweats, multiple joint pains and breathlessness for 5 months. Eight months before the present episode, she had developed a generalised rash and transient swellings in the groin on both sides. Physical examination revealed pallor, pedal oedema and a hyperpigmented rash over the chest, back and thighs. Pulse was 126 beats per minute and respirations 38/min; while breathing ambient air, the oxygen saturation by pulse oximetry was 83%. On auscultation of the chest, breath sounds were diminished bilaterally and crepitations were heard in both the lung bases. Neurological examination revealed weakness of proximal muscles of both upper and lower limbs on both sides with a power of grade 3/5. Laboratory investigations revealed elevated total leucocyte count with neutrophilic leucocytosis; band forms and metamyelocytes were seen in the peripheral blood smear. Oxygen inhalation and broad-spectrum intravenous antibiotics were initiated. Echocardiogram showed severe tricuspid regurgitation with moderate pulmonary arterial hypertension. Computed tomography (CT) of the chest revealed patchy consolidation in both the lungs, bilateral pleural effusions and pericardial effusion. Bone marrow biopsy showed normocellular normoblastic marrow with erythroid hyperplasia. 18F-fluorodeoxyglucose positron emission tomography-CT showed metabolically active lymphadenopathy both above and below the diaphragm and bilateral patchy lung infiltrates. Biopsy of the inguinal lymph node along with immunohistochemistry staining confirmed the diagnosis as T-cell lymphoma.