A case of primary soft-tissue lymphoma of the lower extremity complicated with bacterial infection in a patient with acquired immunodeficiency syndrome

Jingru Zhou; Yibo Lu

doi:10.4103/RID.RID_29_22

CASE REPORT

Year : 2022 | Volume : 9 | Issue : 4 | Page : 155-158

A case of primary soft-tissue lymphoma of the lower extremity complicated with bacterial infection in a patient with acquired immunodeficiency syndrome

Jingru Zhou, Yibo Lu
The Fourth People's Hospital of Nanning, Guangxi AIDS Clinical Treatment Center, Nanning Infectious Disease Hospital Affiliated to Guangxi Medical University, Nanning, China

Date of Submission	05-Jul-2022
Date of Decision	21-Sep-2022
Date of Acceptance	19-Nov-2022
Date of Web Publication	21-Mar-2023

Correspondence Address:
Yibo Lu
The Fourth People's Hospital of Nanning, Guangxi AIDS Clinical Treatment Center, Nanning Infectious Disease Hospital Affiliated to Guangxi Medical University, Nanning
China

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/RID.RID_29_22

Abstract

A patient with primary skeletal muscle lymphoma underwent plain and contrast-enhanced computed tomography (CT) and a pathologic diagnosis was made. The affected muscles were diffusely swollen, with recognizable outlines and clear borders. Contrast-enhanced CT showed mild-to-moderate enhancement, and the spaces surrounding the muscle and subcutaneous fat were narrowed and blurred. Primary skeletal muscle lymphoma is relatively rare and not very specific in its imaging manifestations. The final diagnosis depends on a biopsy of the lesion and immunohistochemistry.

Keywords: Acquired immunodeficiency syndrome, computed tomography, peripheral t-cell lymphoma

How to cite this article:
Zhou J, Lu Y. A case of primary soft-tissue lymphoma of the lower extremity complicated with bacterial infection in a patient with acquired immunodeficiency syndrome. Radiol Infect Dis 2022;9:155-8

How to cite this URL:
Zhou J, Lu Y. A case of primary soft-tissue lymphoma of the lower extremity complicated with bacterial infection in a patient with acquired immunodeficiency syndrome. Radiol Infect Dis [serial online] 2022 [cited 2023 Jun 3];9:155-8. Available from: http://www.ridiseases.org/text.asp?2022/9/4/155/372192

Introduction

Acquired immunodeficiency syndrome (AIDS)-associated lymphoma often occurs in patients with advanced AIDS and may affect organs outside the nodes that are rich in lymphoid tissue (gastrointestinal tract, liver, lungs, central nervous system, nasopharynx, etc.); lymphomas occurring in muscle soft tissues are relatively rare, and the clinical presentation is dominated by painless, progressive local masses, and the initial symptoms are often nonspecific, as reported in the literature mostly in lower limb muscles,^[1] while muscle tissue is affected, it may also invade adjacent skin, subcutaneous, interstitial muscle fat, and other structures,^[2] and diagnosis is difficult due to the lack of knowledge of the disease by clinical or imaging physicians. The purpose of this case report is to analyze the imaging signs of computed tomography (CT) plain scan as well as an enhanced scan of a case of lower-extremity muscle soft-tissue lymphoma confirmed by pathologic biopsy to improve the understanding of this rare disease.

Case Report

Summary of the patient's medical records

The patient was a 74-year-old male who was admitted to the hospital on January 21, 2022, owing to “a penetrating wound on the right foot and ulceration and exudation for 6 months.” The patient reported that in July 2021, his right foot was accidentally stabbed by a branch when cutting a tree, causing the skin to ulcerate. He did not seek medical care for a diagnosis and treatment. He was diagnosed with human immunodeficiency virus antibody-positive in May 2021 and had been virus-free to this point.

Specialist physical examination findings

Skin and soft-tissue contusions were present on toes 1–3 of the right foot. The wounds measured approximately 3 cm × 6 cm and were located deep to the muscle layer. There was a yellow–brown exudate, the wounds were slightly odorous with granulation tissue at the base, and a normal pulse was present in the dorsal pedal artery. A large mass on the inner right thigh was palpable, with medium-firm texture and tenderness.

Laboratory test results

human immunodeficiency virus antibody: positive, cluster of differentiation (CD) 4 (+), T-lymphocyte count: 214/μL, white blood cells: 4.6 × 10⁹/L, red blood cells: 3.92 × 10¹²/L, hemoglobin: 104 g/L, platelets: 269 × 10⁹/L, neutrophil ratio 63.8%, C-reactive protein concentration: 18.7 mg/L and procalcitonin: 0.13 ng/ml.

Imaging examination findings

Plain and contrast-enhanced CT of the right thigh: irregular soft-tissue density shadows were seen in the right adductor magnus and gracilis [Figure 1]a, [Figure 1]b, [Figure 1]c, with clear borders, lobulated edges, and uneven density (sustained enhancement); small blood vessels were visible in these areas [Figure 1]d and [Figure 1]e. The adjacent muscles and blood vessels were compressed and displaced, and the spaces surrounding the muscle and subcutaneous fat were narrowed and blurred. Right foot plain and contrast-enhanced CT revealed soft-tissue swelling, skin thickening, focal defect in the right first toe, irregular soft-tissue density shadows [Figure 2]a and [Figure 2]b, uneven density, uneven and moderate enhancement of the lesion on enhanced imaging, and patchy low interior density without a strengthening zone [Figure 2]d. Irregular areas of bone destruction were seen in the right first toe proximal and distal phalanges [Figure 2]c.

Figure 1: (a-c) Plain computed tomography images, axial and sagittal views, of the right thigh showing irregular soft-tissue density shadows in the right adductor magnus and gracilis. (d) Arterial phase contrast-enhanced computed tomography image showing that the lesions are moderately enhanced in a ring shape, and small blood vessels are seen connecting the surrounding blood vessels, which are compressed and displaced. (e) Venous phase contrast-enhanced computed tomography image showing continuous enhancement of the lesion

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Figure 2: (a and b) Plain computed tomography image, axial view, of the right foot showing an irregular soft-tissue density shadow in the right first toe. (c) Bone window showing irregular bone destruction of the right first toe proximal and distal phalanges. (d) Venous contrast-enhanced image showing moderately heterogeneous enhancement of the lesion

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Pathological diagnosis

Immunohistochemistry results: Granulation tissue on the surface of the wound on the right foot [Figure 3]a large amount of necrotic tissue with neutrophil infiltration is visible, and some atypical cells with large nests of hyperchromatic nuclei have infiltrated the tissue. Photomicrograph of the tissue biopsy specimen of the right thigh mass [Figure 3]b showing that most of the tissue is necrotic, and the residual focal lymphoid tissue shows diffuse hyperplasia and atypia. cytokeratin (to, vimentin (++), desmin (sm, human melanoma black 45 (5, leukocyte common antigen (+), S-100 (00, MelanA (el, Ki-67 (approximately 99% cells) (+), CD20 (0), CD79a (+), CD3 (+), CD10 (0), CD5 (+), B-cell lymphoma 6 (ym, B-cell lymphoma 2 (+), multiple myeloma oncogene 1 (+), c-Myc (c50% cells) (+), tumor protein p53 (weak +), T-cell intracellular antigen 1 (1, Gallyas–Braak (+), CD56 (6), CD8 (+), CD7 (D), CD4 (D), CD2 (+), Pax-5 (+) and in situ hybridization Epstein–Barr encoding region (eg., the thigh lesion was diagnosed with peripheral T-cell lymphoma.

Figure 3: Photomicrograph of the wound tissue biopsy specimen. (a) Granulation tissue on the surface of the wound on the right foot. A large amount of necrotic tissue with neutrophil infiltration is visible, and some atypical cells with large nests of hyperchromatic nuclei have infiltrated the tissue. (b) Photomicrograph of the tissue biopsy specimen of the right thigh mass showing that most of the tissue is necrotic, and the residual focal lymphoid tissue shows diffuse hyperplasia and atypia

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Discussion

Primary skeletal muscle lymphoma is relatively rare and occurs in middle-aged and elderly people. The peak incidence is between 50 and 60 years of age. Some scholars have reported that primary soft-tissue lymphoma accounts for approximately 0.5% of extranodal lymphomas.^[3] There have been occasional case reports in China with locations in the deltoid muscle,^[4] psoas major,^[5] and erector spinae,^[6] and most reports indicated diffuse large B-cell lymphoma, with very few reporting T-cell lymphoma.^[7] The lesions can be located in the subcutaneous tissue, fascia, and muscle. The involved muscles are diffusely swollen, with identifiable outlines and clear boundaries. In some patients, the intermuscular fascia and fat spaces have disappeared, with mild-to-moderate enhancement on CT and no internal necrosis. Bone marrow infiltration was confirmed by magnetic resonance imaging in some patients.^[8],[9]

The current case was a patient with AIDS, with low immunity and a long disease course. The patient's primary symptom was a nonhealing soft-tissue wound on the right foot with recurrent exudation. The concurrent right thigh mass involved the muscle. The imaging findings of the right thigh mass were similar to those reported in the literature. In the right foot lesion, there were low-density nonenhanced areas and bone destruction. Pathogenic bacteria were cultured in the wound exudate. Therefore, changes caused by bacterial infection and secondary abscesses, and chronic osteomyelitis could not be excluded. The diagnosis was complex in this case because peripheral T-cell lymphoma has a low incidence and lacks specificity in its imaging manifestations.

Conclusion

It is difficult to distinguish peripheral T-cell lymphoma from rhabdomyosarcoma, Ewing's sarcoma, fibromatosis, and poorly differentiated synovial sarcoma. The final diagnosis requires biopsy of the lesion and immunohistochemistry.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethic statement

Not appliable.

Acknowledgment

We thank Jane Charbonneau, DVM, from Liwen Bianji (Edanz) (www.liwenbianji.cn), for editing the English text of a draft of this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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