Hodgkin's Lymphoma Mimicking Interstitial Lung Disease

Abstract

Interstitial lung diseases (ILDs), also called diffuse parenchymal lung diseases, represent a variety of disorders that affect the lung parenchyma and cause various respiratory symptoms. They are classified as either idiopathic or secondary to other known causes. Correct diagnosis is crucial to decide specific treatments, avoid exposure to ineffective or harmful therapies, and inform the patient about the prognosis of the disease. I present a case of Hodgkin's Lymphoma presenting initially as ILD.CASE PRESENTATION: A 33-years-old male with a past medical history of poorly controlled diabetes type 1 and chronic kidney disease was admitted for shortness of breath and fatigue starting a few weeks before admission and progressively worsening. Vital signs were significant for tachypnea with RR of 30/min. His oxygen saturation was 66% on room air requiring 60 Ls of oxygen with FIO2 of 60%. He was afebrile. Examination revealed moderate respiratory distress, mild intercostal retractions, and bilateral lung rhonchi. Also, he had mobile and non-tender right posterior cervical lymphadenopathy. CT scans showed extensive bilateral ground-glass interstitial opacities, bilateral pleural effusions, and right cervical lymphadenopathy. Labs showed WBCs of 25.5 K/uL with absolute eosinophils of 1500/uL, CRP 11.3 mg/L, procalcitonin 0.15 ng/mL, and IgE 2785 UI/ml. He was started on IV antibiotics and antifungals without significant improvement. Thorough infectious, cardiac, and hypersensitivity workups were all negative. A bronchoscopy with bronchoalveolar lavage (BAL) was also performed and the differential cell profile was normal. Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) was performed from multiple lymph node stations. Histopathology did not show identified lymphoid components and was declared non-diagnostic. An excisional biopsy of the right cervical lymph node was performed with the histopathology results later confirming nodular sclerosing Hodgkin's Lymphoma (NSHL). The patient was started on Brentuximab plus AVD chemotherapy per oncology recommendations. Further tests and imaging for staging were done as well. His oxygen requirements improved significantly, and he was discharged on 2L of O2 on exertion via nasal cannula.DISCUSSION: Lymphomas can involve the lungs either as primary if there is no nodal or extrapulmonary involvement or secondary. They can present radiologically as solitary masses, multiple nodules, or in a diffuse pattern mimicking ILD. Although lymphoma presenting with lung involvement is not unusual, the uniqueness of this case lies in the radiologic presentation.CONCLUSIONS: Excisional biopsies are typically used to diagnose lymphoma, but EBUS-TBNA is a minimally invasive diagnostic procedure, that was found in multiple studies to be a valuable tool even with "negative" results.