key: cord-0025961-kbqe67v6
authors: Jain, Esha; Al-Tarbsheh, Ali Hani; Oweis, Jozef; Jacobson, Erik; Shkolnik, Boris
title: Hodgkin’s Lymphoma Presenting as Multiple Cavitary Lung Lesions
date: 2021-12-01
journal: Eur J Case Rep Intern Med
DOI: 10.12890/2021_003024
sha: 9799a6826e4f6edc062a8a2da8d756c2bbb2fee5
doc_id: 25961
cord_uid: kbqe67v6

Hodgkin Lymphoma (HL) typically presents similarly to an infectious etiology, thus awareness of its atypical presentations is essential. We present a case of an adult woman who was found to have HL after presenting with a dry, non-productive cough and showing cavitary lesions on chest computed tomography (CT). We also describe the clinical, laboratory, and radiological workup done leading to the diagnosis and management of HL in a critical care setting. LEARNING POINTS: Cavitary lung lesions, particularly multiloculated, are often caused by mycobacterium tuberculosis (TB), aspergillosis, granulomatosis with polyangiitis, sarcoidosis, and rheumatic nodules. Pulmonary infiltration is a rare disorder of an extra-nodal site in Hodgkin’s Lymphoma. The mediastinum and head and neck regions remain the most common sites affected by HL. Radiologically, primary pulmonary HL may mimic pneumonia, carcinoma making the diagnosis unclear.

Hodgkin Lymphoma (HL) with pulmonary involvement is much less commonly observed than classic HL. About 15-40% of cases of Hodgkin's lymphoma include pulmonary involvement [1] . Pulmonary manifestations are most commonly observed through secondary involvement, while primary pulmonary Hodgkin lymphoma is relatively rare. Typically, HL can present as a single nodule, multiple nodules, or a mass. Although cavitary lesions can result from chemotherapy, multiple cavitary lesions are extremely uncommon at the time of diagnosis [2] We present a case of a young adult woman who presented with a chronic dry cough and was found to have HL, nodular sclerosing subtype.

A 26-year-old African American woman with a past medical history of asthma, allergic rhinitis, and infectious mononucleosis presented with a 3-month history of a dry, non-productive cough. Her symptoms began while traveling from Albany, New York to New Orleans Louisiana for work. She returned to the northeast about 1.5 months before presenting to Albany Medical Center with persisting symptoms. Upon her return, she noted a lump in her left side of the neck that had been stable in size but was painful upon coughing. In a questionnaire she reported night sweats and negative for fever, chills, chest pain, shortness of breath, or weight loss.

The patient denied any history of tobacco use, incarceration, or homelessness. She noted no recent contact with sick persons. Blood pressure on admission was 114/88 mm Hg, heart rate was 95 beats/min, respiratory rate was 16/min, and temperature was 36.8°C. Her oxygen saturation was 97% in room air. Physical examination revealed immobile, hard, and non-tender 2x2 cm left supraclavicular lymph nodes on palpation. Laboratory testing resulted in a complete blood count with a hemoglobin level of 10.4 gm/dl, a hematocrit level of 34.4%, a white blood cell count of 9,000/m3, a platelet count of 492,000/mm 3 , and MCV 91.5 fL. Automated differential blood test showed neutrophils 61%, lymphocytes 21%, monocytes 8%, and eosinophils 9% (absolute eosinophils 0.8%). The complete metabolic panel disclosed electrolytes within normal limits, albumin elevated measuring 3.3 gm/dL, and lactose dehydrogenase (LDH) elevated measuring 192. The patient underwent an infectious and malignancy workup involving radiographic imaging, cultures, and serology. Chest CT revealed a large mediastinal mass (12x7x8cm) infiltrating the medial left upper lobe with regions of hypodensity (Fig. 1) . Chest CT also revealed multiple bilateral cavitary lung nodules and masses of varying sizes, predominantly in the upper lobes. A single nodule was observed in the right upper lobe (Fig. 2) . The largest lobulated mass measured about 8 x 6 x 4 cm. Additionally, radiography revealed enlarged mediastinal and left supraclavicular lymph nodes. Infectious workup was negative for acid-fast bacterial (AFB) cultures, histoplasmosis, aspergillus, serum quantiferon, fungitell assay, human immunodeficiency virus (HIV), and SARS CoV-2. Serology showed negative EBV IgM, positive EBV IgG, EBV early antigen, EBV nuclear antigen, and a negative EBV by PCR.

Primary pulmonary Hodgkin's lymphoma and a review of the literature since

Hodgkin's lymphoma with cavitating lung lesion mimicking tuberculosis: A rare presentation

HodgkiŽ s lymphoma

Giant thoracic mass: an unusual presentation of primary pulmonary Hodgkin's lymphoma

Pulmonary manifestations of Hodgkin's disease: radiographic and CT findings

A Diagnostic surprise: primary Hodgkin's lymphoma of the lung

Multiloculated cavitary primary pulmonary Hodgkin lymphoma: case series

Differential diagnosis of cavitary lung lesions

Primary pulmonary hodgkin's lymphoma: a rare etiology of a cavitary lung mass