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Neuroradiology Case of the Week

Case 78

Ravinder Sidhu MD, Jeevak Almast MD, Leena Ketonen MD, PhD,
and P-L Westesson MD, PhD, DDS

Clinical Presentation: A 39-year-old male with HIV positive status presented with pain and swelling on left side of face.

Radiological Findings:  X-ray showed haziness in the left maxillary antrum. The inferior wall of the maxillary antrum was eroded (Fig. 1). On CT the maxillofacial region revealed a large soft tissue mass of the left maxillary sinus which extended into the cheek (Fig. 2 A). There was destruction of the adjoining maxilla and part of inferior alveolar ridge (Fig. 2B). No extension of mass was seen into nasal cavity or orbit.

Diagnosis: Plasmablastic lymphoma

Discussion:  Lymphoma is one of the most common malignancy in patients with human immunodeficiency virus (HIV). It occurs 26-60 times more frequently in HIV-infected patients than in the general population. This neoplasm in acquired immunodeficiency syndrome patients is a highly aggressive tumor and tends to develop in extranodal sites, such as the central nervous system, digestive tract and bone marrow. Lymphoma involving paranasal sinuses is rare in HIV-infected patients and is likely to be confused clinically and radiographically with sinusitis [1].
     Clinically, patients present with local pain, facial swelling and nasal discharge. Radiologically, sinus radiographs usually show opacification, while CT and MRI show opacification, bony destruction, and invasion of adjacent bony structures. Whenever, a sinus radiograph shows opacification with adjacent bony destruction in an immunocompromised patient, infection particularly fungal (mucormycosis, aspergillosis), lymphoma and squamous cell carcinoma should be considered in the differential diagnosis. The invasion of adjacent bony structures can be seen in fungal, lymphomatous as well as in squamous cell carcinoma. Biopsy is always necessary to differentiate a malignant process from infection and to confirm the diagnosis [2,3].

References:

1. Forno AD, Borgo CD, Turriziani A, Ottaviani F, Antinori A, Fantoni M. Non-Hodgkin’s lymphoma of the maxillary sinus in a patient with acquired immunodeficiency syndrome. J Laryngol Otol 1998; 112:982-985.
2. GS Kramer, RA Gatenby. Malignant plasmacytoma appearing as
   invasive paranasal sinus disease after cardiac transplantation. AJNR
   Am J Neuroradiol 1996; 17:1582-1584.
3. Kondo M, Hashimoto S, Inuyama Y, Okamoto R, Yamada F. Extramedullary plasmacytoma of the sinonasal cavities: CT evaluation. Journal of Computed Assisted Tomography. 1986; 10:841-844.