Knee-Deep in Bias: When the Low-Probability Diagnosis of Double-Expressor Lymphoma Wins

In resource-constrained, geographically isolated regions like the Commonwealth of the Northern Mariana Islands (CNMI), diagnostic delays can have profound consequences, particularly for aggressive lymphomas. This case report details the journey of a 32-year-old female originally from Tinian, whose initial presentation of knee pain was attributed to gout, masking an underlying double expressor subtype of diffuse large B-cell lymphoma. The limitations in CNMI, including the absence of MRI, prolonged referral pathways, a lack of specialists, and logistical hurdles in obtaining specialized molecular diagnostics, significantly delayed accurate diagnosis. Over months, her condition progressed to include lytic bone lesions, soft tissue masses, and ultimately, widespread systemic involvement requiring definitive management at a higher-level facility. The case underscores how resource disparities in remote settings can obscure rare diagnoses, emphasizing the need for heightened clinical suspicion, innovative diagnostic strategies, streamlined referral processes, and/or expansion of virtual healthcare to improve outcomes in such vulnerable populations.