CTICasesPleural and Nodal Large B-Cell Lymphoma
Imaging findings
A CT pulmonary angiogram performed for suspected pulmonary embolism showed no embolism but subtle pleural fluid; the fluid attenuation was higher than simple fluid and there was an extrapleural fat sign indicating pleural thickening rather than pure effusion, plus mildly enlarged axillary and internal mammary lymph nodes that were initially overlooked. Diagnostic thoracentesis revealed abnormal lymphocytes, and subsequent PET and axillary lymph node biopsy confirmed pleural and nodal large B-cell lymphoma with dramatically abnormal, thickened pleura and extensive nodal disease.
Key takeaways
Do not scroll through a seemingly simple pleural effusion too quickly: attenuation greater than water and an extrapleural fat sign should raise suspicion for pleural thickening or malignancy rather than benign fluid, and abnormal lymph nodes become much more concerning once pleural disease is recognized. This also illustrates a pitfall of early-arterial-phase PE-protocol CT, which may not allow enough time for pleural or nodal enhancement, so delayed imaging is important when basal or pleural abnormalities are suspected.
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