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HEMATOLOGY & ONCOLOGY dL) and 140 mg/dL (40-230 mg/dL) respectively. Serum protein electrophoresis showed a monoclonal protein band in the gamma region at 5.9 g/dL (0.5-1.6 g/dL), which was further classified as IgG kappa. Kappa/ lambda ratio was calculated at 3.7. His blood repeatedly clotted in the tube despite multiple attempts. Some tests were unable to be performed due to increased serum viscosity. He had inconsistent sodium levels ranging between 113-150 mEq/L without intervention. Hepatic function tests were normal, hepatitis B and C were negative, and cryoglobulin testing was negative. Peripheral flow cytometry showed no abnormal population of B or T cells. CT of the chest, abdomen, and pelvis showed bilateral axillary, subpectoral, mediastinal, upper abdominal, and retroperitoneal lymphadenopathy with no hepatomegaly or ascites. Skin biopsy of the right thigh showed granular deposition of IgM and C3 in the superficial vessels of the skin consistent with leukocytoclastic vasculitis. Excisional biopsy of the left axillary lymph node showed a small B-cell lymphoma with plasmacytic differentiation. Flow cytometry demonstrated a CD20 +, CD5-, CD10-, monoclonal population. CD138 staining showed a separate abundant plasma cell population and kappa light chain restriction. Ki 67 was 10 percent. Bone marrow biopsy showed no evidence of disease. These findings are consistent with lymphoplasmacytic lymphoma (LPL).

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The patient reported having 1 week dyspnea on exertion. She noted to have fevers, intermittent chills, night sweats, dry persistent cough, and diarrhea. Patient had history of asthma during childhood. She had been using electronic cigarettes with marijuana 4 days a week for at least 6 months, however due to news reports she recently stopped prior to presentation. Cartridges would last unaltered for 1 week from dispensaries. Vitals signs were notable for tachycardia and pulse oximetry of 86% on ambient air. Pulmonary exam showed scattered rales with no wheezing. Laboratory results showed a leukocytosis of 28,000 cells/mm3, procalcitonin was 0.64 ng/mL (normal < 0.08 ng/mL), and nasopharynx swab detected human rhinovirus/enterovirus on polymerase chain reaction (PCR). Due to continued oxygen desaturation on ambient air and tachycardia for two-day duration despite antibiotics and supportive care a high-resolution computed topography (HRCT) of the chest was obtained. HRCT demonstrated widespread ground glass opacities and scattered septal thickening bilaterally without lobar predominance, with diffuse subpleural sparing. There were dense consolidations seen bilaterally. Bronchoalveolar lavage (BAL) with a transbronchial biopsy were performed. Right middle and left upper lobe BAL pathology revealed oil-red O stain showing intracytoplasmic lipid droplets in alveolar macrophages consistent with lipid laden-macrophages. Transbronchial biopsy showed pneumonitis; there was interstitial edema, inflammation, mild fibrosis, hyperplasia of type II pneumocytes. Patient was treated with corticosteroids resulting in improved oxygenation.

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