A 49-year-old man was evaluated for left jaw pain and swelling. He had a left neck mass that he noticed a week prior to presentation, which had rapidly enlarged and become painful. The patient also had a two-month history of an enlarging left lower eyelid mass (). The patient denied fevers, chills, or weight loss, but admitted to having night sweats. He had no recent history of oral abscesses or dental procedures and denied having any ocular pain, dysphagia, dypsnea, or difficulty breathing. He denied having a history of Human Immunodeficiency Virus (HIV).
The rapidly enlarging mass of the left lower eyelid had a smooth surface and was moderately tender to palpation.
Computed tomography (CT) of the head and neck revealed a large soft tissue mass in the left lower eyelid, measuring 5×4cm. The mass extended into the superomedial orbit, compressing and displacing the globe laterally. Additionally, the CT revealed a 5×5cm neck mass with central necrosis as well as enlarged submental and bilateral jugular lymph nodes. The findings were suspicious for an abscess, and the patient underwent biopsy with incision and drainage of the neck mass and biopsy of the left lower eyelid mass. Cultures from the neck mass were negative. The patient gave permission for a laboratory testing for HIV, and it showed that he was positive with a CD4 count of 187/mm3 and a viral load of 131,000 copies/mL.
Microscopic examination of the eyelid specimen was performed (). Special stains for fungi and bacteria including acid-fast bacilli were negative. Immunohistochemical stains were positive for CD45, CD68, and Ki-67 in many cells with Ki-67 cell fraction of 50% (), CD20 in the small round cells (), and CD3 in scattered cells, but negative for Human Herpes Virus 8 (HHV8), Epstein-Barr Virus (EBV), and CD30, which excluded the possibility of a CD30+ lymphoproliferative lesion. Fluorescence in situ hybridization on formalin-fixed tissue showed no rearrangement involving the c-MYC gene. The histopathologic findings in the neck mass specimen were similar to those in the eyelid mass. (The neck mass was actually an enlarged lymph node in the neck). Taken together, both were classified as diffuse large B-cell lymphoma (DLBCL).
A. The eyelid biopsy is infiltrated with numerous momonuclear cells, including large cells with round, vesiculated nuclei and prominent nucleoli with abundant cytoplasm. There are small lymphocytes also present. (hematoxylin and eosin, 100X)
Following the diagnosis, the patient underwent a bone marrow biopsy and lumbar puncture, which showed no lymphoma cells, and the lymphoma was determined to be at least Stage 3. The patient was treated with chemotherapy utilizing the CHOP regimen (cyclophosphamide, hydroxydoxorubicin, oncovin, prednisone) and started on anti-retroviral therapy along with prophylactic bactrim. At the four-week follow-up examination, both the eyelid and neck masses were significantly reduced in size. However, the patient has since been lost to subsequent follow-up, and the hospital staff has not been able to contact the patient.