RIGHT DIAGNOSIS FOR
THE RIGHT TREATMENT

Rare presence of Hodgkin’s Lymphoma and
how best to deal with it

A 31-year-old male patient, non-smoker, was admitted to a hospital in Mumbai for a Renal Tubular Acidosis (RTA). A CT scan was done which revealed cavitating Lung Lesion and Hilar Lymphadenopathy. Subsequently, he was put on Antitubercular therapy.

The patient was later referred to Nanavati Super Speciality Hospital with persistent fever, ongoing weight loss (59 to 41 kg) and cough despite taking ATT for 6 months.

Investigations revealed Anaemia, Leucocytosis, and High ESR. Sputum for gram stain culture, AFB smear and Xpert MTB/RIF was negative. An HRCT chest scan was done which showed consolidation with internal cavitation



and necrosis with multiple fibronodular lesions in bilateral parenchyma. A 7.5 x 5 cm necrotic lymph node was seen in the anterior superior mediastinum.

A CT guided lymph node biopsy revealed necrotic tissue. Gram stain, culture, AFB smear, TB gene Xpert MTB/ RIF and fungal culture were negative. A bronchoscopy with BAL and lung biopsy revealed Aspergillus flavus in fungal culture. The serum and BAL galactomannan levels were positive. Aerobic / anaerobic culture, AFB smear,

Xpert MTB-RIF were negative. Lung biopsy revealed no evidence of invasive fungal disease. He was started on Voriconazole. The patient developed itching all over the body and altered sensorium, but no focal deficits or neck rigidity were noted. An MRI Brain with contrast did not reveal any abnormality and CSF studies did not show any abnormality. All aerobic, TB and fungal cultures were negative. Since altered sensorium is a rare but possible side effect of Voriconazole, it was stopped. The patient improved neurologically. However, the fever spikes persisted. Due to high WBC counts, despite antibiotics, a bone marrow biopsy was done, however, histopathological and microbiological studies were normal. A PET-CT was done and it revealed a cavitating lung mass and the presence of metabolically active new left supraclavicular lymph node.

A surgical excision biopsy of the left supraclavicular lymph node was performed and it revealed the presence of classical Hodgkin’s Lymphoma and Reed Sternberg cells. The patient was started on Adriamycin, Vincristine, and Dexamethasone. Bleomycin was omitted in view of lung involvement and poor pulmonary reserve. Antitubercular therapy was stopped. The patient showed remarkable clinical benefits with weight gain, disappearance of fever and significant improvment in PFT. Lymphadenopathy and lung lesions showed near complete resolution at the end of the 4th cycle.

This is an example of atypical and rare presentation of Hodgkin’s Lymphoma as a necrotizing cavitary lung lesion, mimicking an infective pathology. There is a need for extensive investigations including multiple tissue biopsies to pin down the diagnosis.