![]() ![]() Multiple tiny pulmonary nodules up to 10 mm were also present. There was associated widespread lymphadenopathy involving the supraclavicular, mediastinal, abdominal, and pelvic regions. One sacral lesion extended into the left S1 neural foramen. Serial magnetic resonance imaging (MRI) and computed tomography (CT) of his chest, abdomen, and pelvis showed progressive and aggressive-appearing mixed sclerotic-lytic lesions in his iliac and sacral regions. A physical examination was notable for “shotty” supraclavicular lymphadenopathy.Īn initial evaluation at an outside institution was ultimately inconclusive. A review of his symptoms was otherwise unrevealing with no constitutional symptoms. Over a span of approximately 6 months, his left leg tightness and soreness progressed to include his left low back along with sensory changes along his left lateral foot and heel that rendered him with intermittent physical limitation. His family history was notable for a maternal history of bladder cancer a social history disclosed a remote 13-year chewing tobacco history with current cigar smoking accruing to approximately 1.3 cigar-years. ![]() He had no significant past medical history but did have an extensive international travel history from his military service. Musculoskeletal pain is an uncommon presentation and can sometimes be misdiagnosed as osteomyelitis.Ī previously healthy 38-year-old white man presented with left leg tightness and soreness. In 20 to 40% of patients, classic B-symptoms including fevers, night sweats, or unintentional weight loss are present. In approximately 70% of patients, classical Hodgkin lymphoma presents with painless lymphadenopathy predominantly in the cervical or supraclavicular lymphatic chain distribution and, second most commonly, with an asymptomatic mediastinal mass. This infiltration into lymphoid tissue and surrounding organs produces disease and symptoms. On histopathologic examination, pathognomonic Reed–Sternberg cells and other neoplastic variants are present in a mixed inflammatory infiltrate. It is thought that the development of B cell-derived neoplastic cells arises from dysregulation of a network of transcription factors at lymphoid germinal and post-germinal centers. ![]() However, the etiology and mechanism of disease have yet to be fully elucidated. Treatment regimens developed over the years have become highly effective, and commonly used regimens in use today have remission rates approaching 80 to 90% after the initial course. Age distribution is classically bimodal and, in industrial nations, peaks at the second and after the sixth decade of life. Hodgkin lymphoma accounts for approximately 10% of all known lymphomas and has an annual incidence rate of approximately three cases per 100,000 people. Had the additional open bone marrow biopsy not been performed, the diagnosis and treatment of Hodgkin lymphoma would have been missed. This case illustrates diagnostic difficulties of a musculoskeletal presentation of Hodgkin lymphoma, challenges of non-diagnostic bone marrow and lymph node biopsies, and resultant diagnostic delays in delivering a potentially curative therapy. A chemotherapy regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine was instituted with complete symptomatic and radiologic response. An open bone marrow biopsy was performed and yielded a diagnosis of classical Hodgkin lymphoma after 13 months of diagnostic uncertainty. He was treated with non-steroidal anti-inflammatory medications with partial clinical response but had persistent symptoms. Having met the criteria, a tentative diagnosis of chronic recurrent multifocal osteomyelitis was given. Multiple core needle bone marrow and excisional lymph node biopsies were non-diagnostic. Imaging studies revealed multifocal lytic and sclerotic osseous axial lesions. Case presentationĪ 38-year-old white man presented with lower extremity musculoskeletal pain. In this case, we report an unusual presentation of classical Hodgkin lymphoma and highlight diagnostic challenges leading to the misdiagnosis and treatment as chronic recurrent multifocal osteomyelitis. Bony involvement and musculoskeletal symptoms are uncommon and typically seen in advanced disease. Hodgkin lymphoma is a hematologic malignancy usually confined to lymphatic structures and commonly associated with constitutional symptoms. ![]()
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