AN UNUSUAL PRESENTATION OF MALIGNANCY

Abstract

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hodgkin’s Lymphoma (HL) is a common malignancy in adolescence and usually presents as lymph node enlargement or a mediastinal mass on imaging. We present a case of a 19-year-old male, who presented with cavitary lung lesions. He underwent multiple invasive tests and a prolonged antibiotic course only to be diagnosed with HL after undergoing a bi-lobectomy. CASE PRESENTATION: A 19-year-old male with a history of cavitary lung lesion presented to the hospital complaining of a chronic cough, fatigue and a thirty-pound weight loss in the past six months. A computed tomography (CT) of chest, on admission, showed a large cavitary lesion (6.7 by 5.6 cm) in the right upper lobe, numerous additional cavitary areas scattered in the right upper and left lower lobe along with mediastinal adenopathy (Figure 1,2). In the past, he had undergone an unremarkable infectious workup, two bronchoscopies and six weeks of antibiotics. Repeat infectious workup including blood cultures, quantiferon gold and acid fast stain came back negative. A transthoracic followed by a transesophageal echocardiogram was negative for endocarditis. Rheumatologic workup showed positive Antinuclear Antibodies with negative reflex, negative cryoglobulins, and rheumatoid factor with normal complements and serum electrophoresis. Due to worsening symptoms he underwent a third bronchoscopy with endobronchial ultrasound guided needle aspiration (EBUS-TBNA) of lymph nodes. The cultures came back negative for bacterial or fungal growth and the lymph node biopsy was negative for malignancy. Due to failure to improve, the patient finally underwent a right upper and middle bi-lobectomy. Surgical pathology came back positive for HL. He was diagnosed with Stage 3B malignancy and is currently undergoing chemotherapy. DISCUSSION: HL usually presents as a mediastinal mass and is diagnosed via lymph node biopsy. If there is pulmonary involvement, typical appearance consists of irregular pulmonary nodules as opposed to cavitary lesions 1.Our patient underwent three negative bronchoscopies and one EBUS-TBNA. This case highlights that bronchoscopies even when employed with EBUS-TBNA have high specificity (90-100%) but low sensitivities (33-66%) in diagnosing lymphomas 2,3. In these cases, consideration should be made to either repeat lymph node biopsy, or to biopsy multiple lymph nodes to help prevent unnecessary testing. CONCLUSIONS: Since HL is a common lymphoma in adolescent age group, it should be high on the differential even with a negative lymph node biopsy. Our case demonstrates an unusual pulmonary presentation of HL and highlights the importance of considering it in the differential to aid in timely diagnosis and management. Reference #1: Diederich S, Link T, Zühlsdorf H, Steinmeyer E, Wormanns D, Heindel W. Pulmonary manifestations of Hodgkin's disease: radiographic and CT findings. European radiology. 2001;11(11):2295-2305 Reference #2: Labarca G, Sierra-Ruiz M, Kheir F, et al. Diagnostic Accuracy of Endobronchial Ultrasound Transbronchial Needle Aspiration in Lymphoma. A Systematic Review and Meta-Analysis. Annals of the American Thoracic Society. 2019;16(11):1432-1439 Reference #3: Sonnekus B. Diagnostic yield of transbronchial needle aspiration for lymphona. African Journal of Thoracic and Critical Care Medicine. 2016;22(3 ):67. DISCLOSURES: No relevant relationships by Kourtney Erickson, source=Admin input No relevant relationships by Sara Godil, source=Web Response No relevant relationships by Kareem Godil, source=Web Response No relevant relationships by Lalita Shastry, source=Admin input