Case Presentation: A morbidly obese 24 year-old male with two recent hospitalizations for abdominal panniculitis and LE cellulitis presented to the ED with several weeks of worsening left abdominal pain and induration meeting SIRS criteria. On both occasions he’d been discharged, following limited improvement on IV antibiotic therapy, with oral antibiotics that he endorsed having taken. CT abdomen in the ED revealed subcutaneous inflammation of the abdomen and bilateral pulmonary nodules that had been noted during a prior hospitalization without additional work-up. A dedicated chest CT in the ED confirmed pulmonary nodules concerning for metastatic disease.

On admission to the floor, the patient was started on vancomycin and ceftriaxone for suspected cellulitis/panniculitis given the above history and SIRS. After again exhibiting minimal improvement on three days of IV antibiotics, a punch biopsy of his indurated abdominal site was obtained and he was scheduled for outpatient PET CT and needle-guided biopsy of his indurated abdomen and lung nodules. He was subsequently discharged on PO Bactrim for seven days.

Initial punch biopsy results suggested a lymphoproliferative disorder, with PET CT demonstrating hypermetabolic lung and liver foci. Ultimately, needle biopsy of the abdomen and lung confirmed Stage II Lymphomatoid Granulomatosis. The patient was referred to Hematology/Oncology, where he was started on alpha-interferon therapy.

Discussion: Lymphomatoid Granulomatosis (LYG) is an EBV-associated lymphoproliferative disorder first classified in 1972. It is characterized by angiocentric, angiodestructive lesions that present as nodules most commonly affecting the lungs (>90% of patients), skin, kidneys, liver and brain. Its relative rarity and non-specific clinical presentation make it difficult to identify. While LYG is frequently associated with immunocompromised men in their 30’s to 50’s, our patient was both immunocompetent and appreciably younger than published median ages. Further confounding the correct identification of his cutaneous nodules is the likelihood the patient had developed genuine recurrent cellulitis in the setting of lymphedema concomitantly. Of note, there is no known previously established association of LYG with either obesity or cellulitis.

Conclusions: Lymphomatoid Granulomatosis represents just the type of rare, non-specific disease imitator with varied presentations whose diagnosis can be easily missed if a broad unbiased differential is not maintained. This case serves as a reminder that LYG does not always follow a typical presentation. It also highlights the potential pitfalls of relying on a diagnosis that 1) doesn’t respond to therapy as expected, 2) fails to account for significant symptoms or signs, and 3) the tendency to attribute either of the above to a patient’s additional comorbidities, particularly obesity.