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.