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

Sir,

Pulmonary involvement in Hodgkin's lymphoma (HL) at presentation is seen in 15%–40% of cases.[1] It commonly manifests as single or multiple nodular lesions. HL producing solitary or multiple cavitary lung lesions is rare. Such a presentation closely mimics other conditions such as metastatic carcinomas, multiple pyemic abscesses, Wegener's granulomatosis, sarcoidosis, and, most importantly, tuberculosis and needs to be differentiated from them.[2] In a country like India wherein the incidence of pulmonary tuberculosis is very high, the diagnostic and therapeutic decision-making is challenging.

We report a 22-year-old female who was referred to us with a 6-month history of fever, asthenia, weight loss, night sweats, and nonproductive cough. Chest X-ray had shown a cavitating lesion in the lung. The cervical lymph node was reported as granulomatous reaction, and she was diagnosed to have pulmonary tuberculosis and treated with antituberculosis therapy (4-drug regimen) for 1 month. On physical examination, the patient was cachectic and had pallor. Firm, mobile, and nontender multiple cervical lymph nodes ranging from 1 to 2 cm in size were present. Respiratory systemic examination revealed dullness with decreased air entry and crepitations in the upper part of the left thorax. The chest X-ray showed nonhomogeneous opacity of the middle lobe of the left lung with cavitation. Computed tomography scan (CT scan) of the chest showed a well-defined lobulated soft-tissue attenuation lesion in the left paramediastinal plane, superior to the hilum and lateral to the pulmonary trunk. Positron emission tomography (PET)/CT showed the presence of hypermetabolic lesions in multiple cervical, mediastinal, retroperitoneal lymph nodes with cavitating lung lesions [Figure 1]. Flexible bronchoscopy was performed and it did not demonstrate any bronchial airway abnormalities. Cytological examination of bronchoalveolar lavage fluid and bronchial washings did not reveal the presence of any malignant cells. Microbiological test for fungi, acid-fast bacilli, and other pyogenic bacteria was negative. Histopathological examination of the cervical lymph node biopsy showed effacement of the nodal architecture with interspersed bands of fibrosis-forming nodules. There was infiltration by numerous atypical binucleated Reed–Sternberg-like cells and mononuclear Hodgkin's cells, suggestive of nodular sclerosis subtype of HL. A final diagnosis of nodal Hodgkin's disease with lung involvement was made.

Figure 1

Positron emission tomography-computed tomography showing hypermetabolic mediastinal lymphadenopathy with cavitating lung lesions

The patient was started on combination chemotherapy ABVD regimen: Adriamycin (doxorubicin) 25 mg/m2 IV, bleomycin 10 U/m2 IV, vinblastine 6 mg/m2 IV, and dacarbazine 375 mg/m2 IV administered days 1 and 15 of a 28-day cycle. Early assessment of therapeutic response by PET/CT imaging after two cycles of treatment showed complete remission of the disease. She was given six cycles of ABVD regimen, and a repeat chest X-ray and PET/CT evaluation showed complete response with resolution of lung parenchymal disease [Figure 2]. The patient continues to be in clinical and radiological remission at 2 years of regular follow-up.

Figure 2

Positron emission tomography-computed tomography at the end of therapy showing normal lung parenchyma

Involvement of the lung parenchyma is more frequent in HL than that in non-HL. The lung is more frequently involved in secondary or recurrent disease than in primary disease.[1] Cavitating lung lesions in HL are rare and are seen more frequently in patients below 30 years of age.[3] Pulmonary involvement in nodal HL has to be differentiated from Primary pulmonary Hodgkin's lymphoma (PPHL) which is a rare entity. Nodular sclerosis is the most frequent histological subtype found in the PPHL presentation, although mixed cellularity subtype has also been described.[4]

HL is often misdiagnosed as tuberculosis, especially in developing countries like India where the latter is highly prevalent because the clinical presentation and laboratory and radiological investigation findings in both the conditions overlap. Quite frequently, tuberculosis may coexist in a patient with HL, making the diagnosis of HL difficult. In nodular sclerosis HL, the histopathology examination of the lymph nodes may show extensive granulomatous reaction mimicking tuberculosis. PET/CT distinguishes between the two conditions.[5]

The diagnosis of cavitary lung lesions in a patient with HL is challenging and is often misdiagnosed as tuberculosis. This entity, though rare, needs to be considered as an important differential diagnosis of cavitary lung lesions, especially in those cases not responding to systemic antimicrobial/antituberculosis therapy.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent form. In the form the patient has given her consent for her PET-CT images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.