A Difficult Case of Hodgkin Lymphoma with Differential Diagnosis of Tuberculosis and Sarcoidosis.
Bottom Line: The clinical symptoms and laboratory findings mimicking tuberculosis and sarcoidosis complicated the diagnostic process.He was diagnosed with Hodgkin's lymphoma after several X-rays, computed tomography, positron emission tomography-computed tomography, laboratory tests and three lymph node biopsy.Clinicians should be alerted on new lesions and symptoms in high risk patients and should repeat diagnostic tests and lymph node biopsies as indicated.
Affiliation: Bezmialem Vakif University , Istambul, Turkey.
We report here the case of a 14-year-old boy with history of fever, weight loss, and mediastinal lymphadenopathy. The clinical symptoms and laboratory findings mimicking tuberculosis and sarcoidosis complicated the diagnostic process. He was diagnosed with Hodgkin's lymphoma after several X-rays, computed tomography, positron emission tomography-computed tomography, laboratory tests and three lymph node biopsy. Clinicians should be alerted on new lesions and symptoms in high risk patients and should repeat diagnostic tests and lymph node biopsies as indicated.
No MeSH data available.
Related in: MedlinePlus
Mentions: A fourteen-year-old boy presented with weight loss, myalgia, depressed appetite, and leg pain and was referred to our pulmonology unite to check out the possibility that he might have tuberculosis. Physical examination revealed cervical lymphadenomegaly, erythema nodosum, and arthritis (Figure 1 for the timeline). White blood cell (WBC) count, hemoglobin (Hb), and erythrocyte sedimentation rate (ESR) were 18,000/mm3, 12 g/dL, and 30 mm/hour, respectively. A thorax computed tomography (CT) scan showed mediastinal extensive lymphadenomegaly. Screening of other members of his family was negative for tuberculosis. The patient had one Bacillus Calmette-Guérin scar. The tuberculin skin test, tuberculosis bacilli examinations of gastric aspirate, and conventional cultures were performed with negative results. Bronchoscopy revealed an appearance consistent with an external compression on the the main lobe of the right lung. Bronchoalveolar lavage was taken during bronchoscopy for microbiological investigations and results were again negative for tuberculosis. After the initial testing and upon recommendations of his relatives, the patient was prescribed prednisone treatment for two weeks because of severe pain. Afterwards lymph node biopsy was done by mediastinoscopy and revealed CD4 dominant T lymphocyte-rich lymphoid cell proliferation with scanty atypical cells looking suspiciously similar to Reed-Stenberg cells. Atypical cells were positive for CD30, some of which were also positive for EBV-I3 and fascin. CD15 was negative. Immunohistochemistry and the morphology did not fulfill the diagnostic criteria of Hodgkin’s lymphoma. Granuloma was absent on pathological investigation of biopsy to conform either tuberculosis or sarcoidosis. As a result of all these findings, the pathologic investigation showed a possible chronic EBV infection or EBV-induced lymphoproliferative disease. EBV VCA IgM, IgG, and EBV DNA copy were negative, positive, and 938, respectively. These results suggested a possible chronic EBV infection. Non-steroidal anti-inflammatory drugs were prescribed. After one month, the patient was hospitalized for his persistent severe pain, arthritis in his right foot, and cervical lymphadenomegaly. As his blood pressure was 150/100 mmHg, enalapril treatment was started. Eye examination revealed uveitis sequelae for which the patient had been treated four months prior. Laboratory examination disclosed WBC: 20,300/mm3, Hb: 9.4 mg/dL, platelets: 612×103/µL, LDH: 225 U/L, and ESR: 44 mm/hr. Thorax CT showed bilateral axillary multiple lymph nodes with a dimension of 20 mm, mediastinal and hiler subcarinal packs of lymph nodes (47×27 mm), a round 47×37×30 mm lesion on the middle lobe of the right lung, and bilateral minimal pleural effusion. Bone marrow examination was normocellular. Because of the suspicion of lymphoma, a 18-Fluoro-deoxyglucose (FDG) CT was performed (Figure 2). Values ranged from 2.3 to 8.7, consistent with the presence of inflammation. Cervical lymph node biopsy was done and lymphoma was excluded with this biopsy and FDG PET-CT. Also granuloma was absent in the biopsy.
No MeSH data available.