Chronic Prurigo: An Unusual Presentation of Hodgkin Lymphoma

Abstract

Background: Prurigo nodularis is a condition of unknown origin defined by papulonodular eruption and intense pruritus. Hodgkin lymphoma often presents nonspecific initial symptoms. An association between systemic malignancy and cutaneous manifestations has long been documented. We report a case of prurigo nodularis as a first presentation of Hodgkin lymphoma. Case: A 35-year-old woman presented with a 2-year history of pruritus. Previously diagnosed with bedbugs, the pruritus persisted even after insect eradication, with the appearance of papulonodular lesions consistent with chronic prurigo. The pruritus and the pain were refractory to all treatments. She had no past medical history or clinical, radiological, or laboratory findings. A lymphadenopathy was revealed 2 years after onset of the symptoms. Lymph node biopsy showed a nodular sclerosis Hodgkin lymphoma. The patient was initiated on chemotherapy and the skin lesions decreased. Conclusion: This case report of chronic prurigo as the first manifestation of a systemic malignancy reminds us of the importance of a systematic diagnostic approach to this kind of patients initially and throughout time, especially if the symptoms do not respond to treatment. Our case may question the role of imaging examinations in the management and follow-up of a persistent prurigo nodularis.

Interleukin-31 as a Clinical Target for Pruritus Treatment

“…Although IL-31 appears to have a role in pruritus in CTCL, there is conflicting evidence as to whether it plays a larger role in the pathogenesis of CTCL itself (56,58,59). However, of note, chronic prurigo has also been reported in cases of Hodgkin lymphoma (HL) (60), and a study in HL patients demonstrated elevated IL-31 in HL cells and in the immune cells infiltrating affected lymph nodes (61). Another recent study showed that plasma concentrations of IL-31 decreased in HL patients entering remission (62); taken together, these findings suggest that IL-31 may contribute to immune suppression in HL, and may indicate a similar role in CTCL.…”

Diagnostic Workup and Evaluation of Patients with Prurigo Nodularis

“…Systemic and metabolic causes have been implicated in 38% to up to 50% of PN cases [25,26]. Some common systemic associations of PN are chronic renal failure, liver disease (chronic hepatitis B, primary biliary cholangitis, chronic autoimmune cholestatic hepatitis), HIV, thyroid disease, diabetes and malignances, specifically non-Hodgkin's lymphoma [3,4,[27][28][29][30][31][32][33][34][35][36]. A study (n = 16,925) by Larson et al found that pruritus was most strongly associated with cancers of the liver, skin, and hematopoietic system [37].…”

“…A study (n = 16,925) by Larson et al found that pruritus was most strongly associated with cancers of the liver, skin, and hematopoietic system [37]. Rarer malignancies that have been associated with PN are metastatic transitional cell carcinoma of the bladder and Hodgkin's lymphoma [30,38,39]. Other less commonly associated systemic causes are gout, iron-deficiency anemia, and celiac disease [26,32,40,41].…”

Clinical characteristics and disease burden in prurigo nodularis

“…PN may initially present as grouped lesions but can disseminate to become more widespread 3 . Although the precise aetiology of PN remains unknown, it has been associated with comorbid dermatological conditions, such as atopic dermatitis (AD), 2,4–6 and with systemic inflammation and several systemic illnesses, including HIV, chronic renal failure, liver disease, thyroid disease and malignancy 2,6–15 . Compared with other chronic itch conditions, the itch of PN is among the most severe 16 …”