A previously healthy 71-yr-old woman visited a physical medicine and rehabilitation clinic with a 2-month history of intermittent upper back pain. The pain worsened with movement of the back and subsided with rest and medication (nonsteroidal anti-inflammatory drugs). The patient felt she had “sprained her back” and did not pay particular attention to this matter until her upper back pain persisted despite hours of rest. Physical examination revealed tender points in the right upper back, with regional muscle spasm, referred pain, and slight limitation of range of motion involving the right shoulder. The physiatrist noticed asymmetrical swelling of the right upper back, which was showing a hypoechoic lesion with distinct borders between muscle layers by musculoskeletal ultrasound. Therefore, a computed tomography (CT) scan was recommended and scheduled.
On the day before the scheduled CT, the patient presented to the emergency department with fever, chills, and abdominal pain. Abdominal sonography findings were consistent with acute cholangitis with intrahepatolithiasis. A routine chest x-ray revealed right pleural effusion and increased infiltrations in the right upper lobe. Blood work showed a hemoglobin level of 11.7 g/dl, white blood cell count of 12,980/mm3 with 2% lymphocytes, 1% metamyelocytes, 3% band cell, and 93% neutrophils. Chest CT scan with contrast (Fig. 1A) was performed immediately and revealed a mass in the right upper posterior chest wall. With CT-guided biopsy, the mass was confirmed as a malignant lymphoma, large B-cell type. Positron emission tomography showed multiple hot spots in the neck, mediastinum, and abdominal viscera, which were compatible with malignant lymphoma (Fig. 1B). With the diagnosis of stage IV b non-Hodgkin's lymphoma, the patient was immediately referred for chemotherapy and target therapy. After 6 wks of treatment, the mass in the upper back decreased in size, and her upper back pain subsided.
Large B-cell lymphoma is the most common type of non-Hodgkin's lymphoma that occurs more commonly in men, with an average age of confirmatory diagnosis at 64 yrs.1 Common clinical presentations include fever, unexplained weight loss, night sweats, and a rapidly enlarging mass in the neck or abdomen with lymph node involvement.2 Upper back pain as the initial presentation of lymphoma is very rare.3,4 However, clinicians should maintain a high level of suspicion regarding the diagnosis of malignancy, especially when a patient presents with worsening pain and an enlarging mass.
1.Morton LM, Wang SS, Devesa SS, et al: Lymphoma incidence patterns by WHO subtype in the United States, 1992–2001. Blood
2.A clinical evaluation of the International Lymphoma Study Group classification of non-Hodgkin's lymphoma. The Non-Hodgkin's Lymphoma Classification Project. Blood
3.Barker PG, Raby ND: A soldier with recurrent back pain. Br J Radiol
4.Grattan-Smith PJ, Ryan MM, Procopis PG: Persistent or severe back pain and stiffness are ominous symptoms requiring prompt attention. J Paediatr Child Health