A 72-year-old man had been suffering from low-grade fever, minimally productive cough, and shortness of breath for 1 week when he experienced sudden, moderately severe right-sided chest pain. His local primary care physician found no abnormalities on physical exam and laboratory testing. A chest x-ray, however, did reveal a small right-sided pleural effusion. The patient was empirically started on levofloxacin but noticed no improvement. Two weeks into his illness, he was referred to our institution for further management. By this time, he reported a rapid 10-pound weight loss and a daily low-grade fever. Chest examination revealed dullness to percussion along with decreased breath sounds in the right posterior lung fields. A complete blood count showed an elevated white count of 17,000/mL with 14,000 neutrophils. Hemoglobin was 13.5 g/dL. A repeat chest x-ray and then a CT scan showed a multiloculated pleural effusion in the right lower hemithorax. Ultrasound-guided tap of this effusion showed cloudy fluid consistent with pus, with a protein of 4.8 g/dL and total nucleated cells of 6000/mL. A gram stain on this fluid was negative.The patient had a history remarkable for severe underlying chronic obstructive pulmonary disease (COPD). His forced expiratory volume in 1 second (FEV1) was 21%, and his diffusing capacity of carbon monoxide (DLCO) was 27%. Therefore, decortication under general anesthesia was not an option. So the largest pus pocket was drained under CT guidance, and the patient was dismissed home on levofloxacin.He returned for follow-up after 3 weeks and reported daily low-grade fever, night sweats, and an additional weight loss of 14 pounds. His white count had risen to 18,300/mL with a neutrophil count of 16,600. Hemoglobin had fallen to 11.9 g/dL. A repeat CT scan showed that although the previously drained fluid pocket had resolved, a moderate amount of fluid had reaccumulated in other pockets. Delayed anaerobic culture results from the hospitalization 3 weeks earlier were now available and, interestingly, showed 2ϩ growth of Campylobacter jejuni, broadly sensitive to all antibiotics including penicillin. Piperacillin/tazobactam was started intravenously, and CT-guided drainage of the largest pus pocket was again performed.We carefully reexamined the patient's CT scan, and there appeared to be a lesion in the right main-stem bronchus. We decided to perform a bronchoscopy, which revealed a foreign body in the right main-stem bronchus. The foreign body turned out to be a piece of chicken and a peanut. On specific questioning of the patient again, he admitted that at times he coughed after eating too quickly. Specifically, he remembered that a few days C A S E R E P O R T

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Background: Absolute lymphocyte count (ALC) recovery is an independent prognostic factor for survival for different hematological malignancies treated with autologous stem cell transplantation. Recently, we reported superior overall survival (OS) in patients with follicular lymphomas that presented with a higher ALC (ALC ≥ 1 x 109/L) at diagnosis. The role of ALC at diagnosis on survival in T cell lymphomas is not known. Methods: All patients evaluated at the Mayo Clinic for T cell lymphomas from October 1984 until April 2005 were analyzed in the study. The primary objective of the study was to assess the role of ALC at diagnosis and survival in T cell lymphomas. ALC at diagnosis was obtained from the standard complete blood cell count (CBC). Results: 223 patients with T cell lymphomas were included in the study. The histology included: peripheral T-cell lymphoma-unspecified (40%), anaplastic large cell (13%), angioimmunoblastic (10%), angiocentric (4%), intestinal T-cell (2%), and other (31%). The median follow-up was 18.6 months (range: 1 month – 229 months [19 years]). The sample population included 60% male and 40% females with a median age of 60 years (15–90 years). The median ALC at diagnosis was 1.2 x 109/L (range: 0.04–6.7 x 109/L). ALC as a continuous variable was identified as predictor for OS in the univariate analysis (HR= 0.690, 95%CI: 0.542–0.862, p < 0.0006). ALC ≥ 1 x 109/L was selected as the dichotomized value because it yielded the maximum difference in survival by c2 analysis looking at different cut-point from 0.6 to 1.7 x 109/L that were included between the 25% and 75% quartiles. Univariately, ALC ≥ 1 x 109/L was also identified as a predictor for OS (HR = 0.682, 95%CL= 0.578–0.804, p < 0.0001). Patients (N = 122) with an ALC ≥ 1 x 109/L experienced superior survival compared to patients (N = 101) with an ALC < 1 x 109/L [median OS: 76.3 vs 10.6 months, respectively; and 5 years OS estimates of 53% vs 23%, respectively, p < 0.0001]. When ALC ≥ 1 x 109/L was compared to the international prognostic index (IPI), ALC ≥ 1 x 109/L remained an independent predictor for survival in the multivariate analysis (HR = 0.779, 95%CL: 0.655–0.925, p < 0.004). Conclusion: This study demonstrates ALC as an independent predictor for OS in T cell lymphomas, suggesting that the host immune system affects survival in this group of patients.