Grade 3 Pulmonary Lymphomatoid Granulomatosis Diagnosed by Robotic-Assisted Bronchoscopy: A Case Report

Lymphomatoid granulomatosis (LYG) is a rare, Epstein-Barr virus (EBV)-associated lymphoproliferative disorder characterized by angiocentric and angiodestructive infiltrates that most commonly involve the lungs. We report a case of a 38-year-old female with a history of latent tuberculosis who presented with a 3-day history of fever, productive cough, bilateral lower extremity edema, and painless lower extremity skin lesions. Initial imaging revealed bilateral pulmonary nodules, and an extensive infectious workup was unrevealing. To obtain diagnostic tissue from peripheral lesions, she underwent robotic-assisted bronchoscopy with targeted transbronchial biopsy. Histopathologic analysis revealed angiocentric and angiodestructive infiltrates with EBV positivity in CD20-positive B cells, consistent with Grade 3 LYG. She was treated with dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (DA-EPOCH-R) chemotherapy, with initial radiographic response. However, she later developed refractory LYG complicated by hemophagocytic lymphohistiocytosis (HLH) and died of progressive disease. Robotic-assisted bronchoscopy enabled safe, targeted sampling of peripheral pulmonary nodules, avoiding more invasive surgical biopsy.