ENDOBRONCHIAL PRESENTATION OF HODGKIN'S LYMPHOMA

Abstract

SESSION TITLE: Lung Pathology 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Lymphomas commonly present with constitutional symptoms and lymphadenopathy. Rarely do they present as endobronchial tumors (1). We report a rare case of endobronchial presentation of Hodgkin’s Lymphoma. CASE PRESENTATION: 66-year old female with diabetes, hypertension, Hodgkin’s lymphoma (diagnosed 1 month prior, with an excisional biopsy of cervical lymph node) status post 1 dose of Rituximab, presented to the ER with fever, cough, chills and a purulent carbuncle on her right thigh. She was afebrile, tachycardic with a heart rate of 107 but otherwise had normal vitals, with an oxygen saturation of 100% on room air. Laboratory results showed Hemoglobin and Hematocrit of 7.4 g/dL and 23.8, and lactic acid of 3.8 mmol/l. CT chest showed multiple patchy opacities in both lungs, large consolidation in the lingula (new compared to her previous scan done 6 weeks earlier), stable mediastinal adenopathy and bilateral axillary adenopathy which was new. Patient was started on broad spectrum antibiotics to cover pneumonia and bronchodilators for symptomatic relief. Despite this patient continued to worsen with regard to her respiratory symptoms requiring commencement of systemic steroids for bronchospasm. Even though she had symptomatic relief, repeat chest imaging showed worsening of lung infiltrates and hence she underwent bronchoscopy. Bronchoscopy showed an endobronchial mass in the left main stem bronchus, resembling a mucus plug. Core biopsy and brushings were sent for histopathological analysis which showed Hodgkin’s lymphoma, classical type. Patient was started on chemotherapy and is currently being followed up in our cancer center. DISCUSSION: Hodgkin’s disease of the lung usually presents as mediastinal lymphadenopathy (2). Presentation of Hodgkin's disease as an endobronchial lesion is uncommon (<5%). The possible mechanism responsible for endobronchial disease is either by direct bronchial invasion or by hematogenous dissemination. Patients usually develop respiratory symptoms due to compression of the airways. Gross appearance of the lesion can mimic small cell cancer. It has been proposed that to be recognized as an endobronchial presentation of Hodgkin's disease, the case has to fulfill the following criteria at the time of initial diagnosis: (i) histological features of Hodgkin's disease (whatever the site of biopsy) and (ii) bronchoscopic visualization of an endobronchial tumor. It is a potentially curable disease with dual chemotherapy regimen. CONCLUSIONS: A bronchoscopy may be warranted in patients that have been diagnosed with Hodgkin’s lymphoma and develop new respiratory symptoms. Though infections should always be in the differential diagnosis, especially as these patients are also immunocompromised, the possibility of endobronchial involvement must be considered. If unrecognized, this can lead to under-staging of a potentially curable disease, that can compromise the cure. Reference #1: 1. Prakash R. Malur, Gajanan S. Gaude, Hema B. Bannur, Shivappa B. Anurshetru, Vijayalaxmi V. Suranagi, Ranjit P. Kangle, Annasaheb J. Dhumale, Pradeep H. Patil, and Reshma Davanagere. Primary endobronchial Hodgkin's disease. Lung India. 2009 Oct-Dec; 26(4): 136–138. Reference #2: 2. Ben Naoum Y, Chapuis E, Coste E, Marty-Double C, Vincent D. [Bronchial presentation of stage IVB Hodgkins disease]. Rev Mal Respir. 2004 Jun;21(3 Pt 1):599-601. DISCLOSURES: No relevant relationships by Anna Abbasi, source=Web Response No relevant relationships by Prarthna Chandar, source=Web Response No relevant relationships by Kabu Chawla, source=Admin input No relevant relationships by William Pascal, source=Web Response No relevant relationships by Anand Rai, source=Web Response No relevant relationships by Ben Shamian, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response