Concomitant Hodgkin's lymphoma with tuberculosis is an exceedingly rare clinical scenario and a condition that is difficult to manage due to similar clinical presentation. This case report describes the same in a 44-year-old male patient diagnosed with Koch's and initiated on antituberculosis therapy, based on confirmation of findings from the spine biopsy and culture. The patient's clinical condition worsened despite being on treatment for tuberculosis. Hence, further work up of the patient was done which included mediastinoscopy and endobronchial ultrasound. Biopsy samples from a conglomerate mass in the lower cervical region and mediastinum revealed Hodgkin's lymphoma of the nodular sclerosis type. This time, the patient showed significant improvement following treatment with chemotherapy and radiotherapy along with antituberculosis therapy.
Keywords: Hodgkin's lymphoma, mediastinal lymphadenopathy, tuberculous spondylitis
| Introduction|| |
Hodgkin's lymphoma has a bimodal presentation, commonly occurring between the age group 20–30 years and in the elderly above 50 years with equal sex preponderance. The most common histopathological subtype of Hodgkin's lymphoma is the variant commonly presenting with mediastinal involvement. On histopathology, nodular sclerosis subtype has the classic Reed-Sternberg cells More Details or its variants. A combination of chemotherapy and radiotherapy remains the cornerstone of treatment in Hodgkin's lymphoma. Tuberculous spondylitis has destruction of the vertebral end plates with relative preservation of the disc spaces commonly involving the lower dorsal and upper lumbar vertebrae. Associated collapse of the vertebral bodies and anterior wedging leads to gibbus deformity and progressive kyphosis. Thoracic vertebrae are commonly affected in tuberculosis with subligamentous spread of infection causing noncontiguous or skip vertebral involvement. Pott's spine presents with clinical manifestations such as back pain, paraplegia, and kyphosis. Magnetic resonance imaging (MRI) is a more sensitive imaging modality than plain radiographs and more specific than computed tomography (CT) scan. MRI frequently demonstrates extent of vertebral body destruction, paraspinal abscess formation, epidural extension into the spinal canal, and curvature deformities. CT-guided needle biopsy from the affected vertebral body is the gold standard technique for the confirmation of histopathological diagnosis. Antituberculosis treatment remains the cornerstone of treatment in tuberculous spondylitis.
| Case Report|| |
A 44-year-old male presented to the department of neurosurgery with complaints of severe low back pain which was associated with night sweats and weight loss for 3 months. Blood counts revealed leukocytosis and increased C-reactive protein. Plain radiographs of the spine revealed osteolytic changes predominantly involving L1–L2 vertebral bodies. Contrast enhanced MRI of the spine illustrated loss of curvature and straightening of the dorsolumbar spine with multiple paravertebral and epidural collections extending between D11 and L2 vertebral levels. An imaging diagnosis of Pott's spine was made [Figure 1]. Incidental screening revealed multiple conglomerate lymph nodes in the left lower cervical [Figure 2], anterior mediastinum and left axillary locations [Figure 3]. Imaging-guided needle biopsy and culture showed colonies of Mycobacterium tuberculosis [Figure 4]. Histopathology of specimen samples from the conglomerate nodal mass of the neck revealed Hodgkin's lymphoma [Figure 5]. The patient was initiated on radiotherapy based on image-guided radiation therapy technique by external-beam radiotherapy delivering a dose of 30 Gy in 15 fractions using 6 MV photons from a linear accelerator. Chemotherapy was initiated with vinblastine, Adriamycin, dacarbazine, bleomycin for six cycles and was simultaneously advised to continue antituberculosis treatment for 9 months' duration.
|Figure 1: Axial T1 + contrast MR image at the level of L1 vertebra demonstrating an enhancing lesion in the vertebral body, prevertebral and paravertebral spaces (arrows). MR: Magnetic resonance|
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|Figure 2: Axial T1 + contrast MR image at the level of D1 vertebra demonstrating an enhancing conglomerate mass in the lower cervical region (arrows). Histopathology of the specimen revealed Hodgkin's lymphoma. MR: Magnetic resonance|
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|Figure 3: Coronal T1 + contrast MR image of the chest demonstrating enhancing conglomerate lymph nodal masses in the lower cervical region, anterior mediastinum and left axilla (arrows). MR: Magnetic resonance|
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|Figure 4: Histopathology image demonstrating granulomas with scattered Langhan's type of giant cells surrounded by lymphocytes and histiocytes consistent with features of tuberculosis (H and E, × 200)|
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|Figure 5: Histopathology image demonstrating classic Reed-Sternberg cells in a background infiltrate of lymphocytes, plasma cells and histiocytes consistent with nodular sclerosis subtype of Hodgkin's lymphoma (H and E, × 400)|
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The case report was approved by the Institutional Ethics Committee (IEC, St. John's Hospital; IEC Approval Reference Number: SJH/52/2020; IEC Approval Date: October 12, 2020). The patient gave informed written consent to publish his case and clinical images.
| Discussion|| |
Dorsolumbar spine is affected in more than 50 % of cases with musculoskeletal involvement of tuberculosis and is most prevalent in adults with no definite sex predilection. Vertebrae of the lower dorsal spine are the preferred sites of tuberculous infection, followed by the upper lumbar levels. Pott's spine is characterized by noncontiguous or skip vertebral involvement with multiple levels being affected with relative preservation of disc spaces. Chronic back pain, loss of appetite, low grade fever, and weight loss are the clinical manifestations of Tuberculous Spondylitis. Delay in diagnosis of Pott's spine leads to complications such as paraspinal abscess and sinus tract formation, epidural extension causing cord compression, myelopathy and paraplegia, and spinal deformity. Mediastinal tuberculosis is characterized by hilar and mediastinal lymphadenopathy that is more often unilateral on the side of Ghon lesion as compared to Hodgkin's Lymphoma that is commonly bilateral. However, mediastinal lymphadenopathy in tuberculosis can have bilateral involvement in children. In primary Hodgkin's lymphoma, lung parenchymal involvement in the absence of mediastinal nodal involvement is extremely rare, whereas in recurrent disease, lung parenchymal involvement is more common which may not be accompanied by mediastinal lymphadenopathy. In patients with mediastinal involvement of Hodgkin's lymphoma, the nodular sclerosis variant is the most common histopathological subtype. The presence of classic Reed-Sternberg cells or its variants on histopathological sections is characteristic of Hodgkin's Lymphoma.
Since Hodgkin's Lymphoma is cell-mediated immunodeficiency, it may result in infections such as Tuberculosis. The coexistence of Hodgkin's Lymphoma and tuberculosis is a rare entity which may delay the diagnosis and treatment of either of the diseases. The diagnostic dilemma between Hodgkin's lymphoma and tuberculosis lies in the similarities in clinical course and findings from imaging studies. Nevertheless, when there is a strong clinical suspicion of tuberculosis, molecular identification and detection of mycobacteria should be performed for accurate diagnosis.
| Conclusion|| |
Hodgkin's lymphoma, nonmycobacterial co-infection, and atypical mycobacterial infection are to be considered in the differential diagnosis when a patient who was previously diagnosed with Tuberculosis shows no signs of clinical improvement despite being on antituberculosis treatment for a significant time period of 6–9 months. Mediastinum should be carefully assessed for Hodgkin's lymphoma in such patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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Department of Radiology, St. John's Hospital, Kattappana - 685 515, Kerala
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]