Keywords
Endobronchial biopsy - endobronchial lesion - endobronchial ultrasound/transbronchial
needle aspiration - Hodgkin lymphoma - mediastinal lymphadenopathy
Introduction
Mediastinal and hilar lymphadenopathy is one of the most common presentation of patients
with newly diagnosed intrathoracic Hodgkin lymphoma (HL), accounting for approximately
40% of cases.[1],[2] Parenchymal and tracheobronchial presentation of HL are rare[1],[2] and seldom associated with symptomatic pericardial effusion.[3],[4] We report a 15-year-old adolescent presenting with symptomatic pericardial effusion
also having endobronchial polypoidal lesion diagnosed with classical HL.
Case Report
A 15-year-old adolescent with no significant history presented with complaints of
fever, weight loss for 3 weeks, acute onset of cough, chest pain, and breathing difficulty
for 2 days. On admission, he was tachypneic (respiratory rate −30/min) and tachycardic
(130/min) with normal blood pressure and saturations. General physical examination
showed mild pallor with no significant peripheral lymphadenopathy. Systemic examination
showed muffled heart sounds with other systems normal.
He was admitted to the pediatric intensive care unit for monitoring and possible further
intervention. His initial investigations were normal (complete blood count, renal
function test, liver function test, Widal test, malarial parasite by peripheral smear,
leptospirosis IgM, blood culture/sensitivity, Mantoux test negative). Two-dimensional
echocardiography showed a significant pericardial effusion and contrast-enhanced computed
tomography of the thorax showed the right upper lobe (RUL) cut of the sign [Figure 1]a, significant mediastinal adenopathy [Figure 1]a and [Figure 1]b with moderate pericardial effusion/pericardial extension [Figure 1]b. Due to worsening distress and tachycardia, pericardiocentesis done, ~500 mL of
straw-colored fluid drained. A differential of tuberculosis versus aggressive non-HL
disease versus HL was considered.{Figure 1}
Figure 1: (a) Computed tomography of the chest shows significant mediastinal adenopathy
with bronchial cut off sign (red arrow), (b) Computed tomography of the chest shows
significant mediastinal adenopathy (yellow triangle)/pericardial extension (orange
arrow), (c) polypoidal growth seen entrance of the right upper lobe bronchus (black
star), (d) transbronchial needle in the target lymphnode (Station 7)
Pleural fluid analysis showed lymphocytic transudate, adenosine deaminase –30 IU/L,
geneexpert negative, and negative for malignant cells.
Postpericardiocentesis, distress, and tachycardia settled but continued to have persistent
fever spikes. As a need for diagnosis was of paramount importance, a bronchoscopy
with endobronchial ultrasound/transbronchial needle biopsy (EBUS/TBNA) of lymph nodes
was planned. Bronchoscopy showed RUL mass lesion obstructing anterior segment of RUL
bronchus [Figure 1]c. EBUS/TBNA [Figure 1]d and endobronchial biopsy of the mass lesion showed classical HL histopathologically
confirmed on immunohistochemistry. Positron-emission tomography/computed tomography
for staging showed Stage IV according to the Lugano classification [Figure 2].[5] He has currently completed two cycles of chemotherapy with no significant adverse
effects.{Figure 2}
Figure 2: (a) Positron‑emission tomography–computed tomography of the chest shows
significant mediastinal adenopathy with increased radiotracer uptake with a standardized
uptake value‑max of 8 (red arrow), (b) positron‑emission tomography‑computed tomography
of the chest shows bronchial cut off sign with increased radiotracer uptake with a
standardized uptake value‑max of 8 (yellow arrow)
Discussion
Mediastinal lymphadenopathy (MLN) is one of the most common manifestations of intrathoracic
HL, accounting to approximately 40% of all cases.[1],[2] Isolated endobronchial,[1],[2],[6],[7] as well as pericardial extension of HL,[3],[4],[8] has been reported in different patients, respectively, but the simultaneous presentation
of both in the same patient, has seldom been. The patient presented with both symptomatic
pericardial effusion and endobronchial mass lesion with significant MLN. Pericardial
involvement, specifically effusion, occurs in approximately 5% of patients with HL,
spread via lymphatic or hematogenous route and is a result of blockage of lymphatic
and venous drainage of pericardial fluid,[8] whereas endobronchial involvement in HL is unclear. Trédaniel et al.[6] and Gallagher etal.[7] reported 3 and 9 patients in there series, respectively, presenting as endobronchial
HL, confirmed by bronchial biopsy.
The patient underwent both endobronchial biopsy of the polypoidal growth and EBUS/TBNA
of paratracheal (4R), right hilar (10R and 11R) lymph nodes with core biopsy for both
histopathological and immunophonotypical diagnosis.
Endobronchial biopsy and EBUS/TBNA showed plenty of binucleated cells seen suggestive
of Reed–Sternberg cells among the lymphocytes and histiocytes. Immunohistochemistry
of the same was positive for both CD15 and CD30, thus making a categorical diagnosis
of classical HL. He has currently completed two cycles of chemotherapy with no significant
adverse effects.
Conclusion
Concomitant endobronchial lesion and pericardial effusion, even though rare can be
the initial presentation of HL and has to be considered a possible differential to
tuberculosis and non-HL.
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understand that their names and initials will not be published and due efforts will
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