Classical Hodgkin lymphoma masquerading as chronic recurrent multifocal osteomyelitis: a case report

Abstract

BackgroundHodgkin lymphoma is a hematologic malignancy usually confined to lymphatic structures and commonly associated with constitutional symptoms. Bony involvement and musculoskeletal symptoms are uncommon and typically seen in advanced disease. 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.Case presentationA 38-year-old white man presented with lower extremity musculoskeletal pain. Imaging studies revealed multifocal lytic and sclerotic osseous axial lesions. Multiple core needle bone marrow and excisional lymph node biopsies were non-diagnostic. Having met the criteria, a tentative diagnosis of chronic recurrent multifocal osteomyelitis was given. He was treated with non-steroidal anti-inflammatory medications with partial clinical response but had persistent symptoms. A second medical opinion was pursued. An open bone marrow biopsy was performed and yielded a diagnosis of classical Hodgkin lymphoma after 13 months of diagnostic uncertainty. A chemotherapy regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine was instituted with complete symptomatic and radiologic response.ConclusionsThis 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. Had the additional open bone marrow biopsy not been performed, the diagnosis and treatment of Hodgkin lymphoma would have been missed.

Acetabular reconstruction with total hip replacement and femoral head autograft following pelvic resection of malignant bone tumour: A case report

“…Classical Hodgkin lymphoma is defined subgroups as: nodular sclerosis, mixed cellularity, lymphocyte depletion, and lymphocyte-rich Hodgkin lymphoma, is characterised by the presence of Hodgkin and Reed-Sternberg (HRS) cells [31] . Classic symptoms includes fevers, night sweats, or unintentional weight loss are present [32] . Being one of the least common in primary bone tumour malignancies had been a diagnostic challenge due to its variable radiographic presentations, the most common radiographic features include permeative, lytic pattern of bone destruction, metadiaphyseal location, periosteal reaction, and soft-tissue mass [33] .…”

“…Staging for this disease are so essential for the optimal therapy. Discriminating solitary bone lesion in HL patients from “primary” to “secondary” is challenging as the diagnosis of primary bone HL should be made based on strict histological and clinical manifestation [34] , [35] , [36] , [37] , [38] .…”

Chronic recurrent multifocal osteomyelitis in a 3.5-year-old boy

“…[ 13 ] Furthermore, a report by Pham et al examined a 38-year-old man who presented with lower extremity musculoskeletal pain with the presentation of Hodgkin lymphoma as a misdiagnosis instead of CRMO. [ 14 ]…”

Hodgkin lymphoma presenting as alcohol-induced back pain

“…However, 20–40% of patients may experience classic B-symptoms, including fevers, night sweats or unintentional weight loss 2. Identification of spinal lesions as the initial manifestation of nodular sclerosis HL is rare, and only sporadic case reports of HL present with musculoskeletal pain 3…”