Diagnostic dilemma of Hodgkin’s lymphoma versus tuberculosis: a case report and review of the literature

Abstract

Background Hodgkin’s Lymphoma (HL) is a rare malignancy characterised histologically by the presence of Reed-Sternberg cells. Diagnosis of lymphomas can be difficult due to broad, non-specific presentations of disease, which can be similar to several other conditions ranging from infective, inflammatory or malignant causes, with one of the most common differentials being tuberculosis (TB). We aim to highlight the diagnostic dilemma of TB versus lymphoma with an atypical presentation of HL and explored areas for further research and improvement with a non-systematic literature review using MEDLINE database and Google Scholar. Written consent was obtained from the patient in compliance with ethical guidelines. Case presentation A 23-year-old Asian female initially presented to rheumatology with over a one-year history of neuropathic pain, alongside abnormal white cell count and inflammatory markers. This was investigated with magnetic resonance imaging resulting in an incidental finding of mediastinal mass and pulmonary infiltrates. An initial diagnosis of TB was made despite testing negative for acid-fast bacilli and anti-tubercular treatment was commenced. Four months later, following clinical deterioration and further investigations, a mediastinal biopsy assisted in diagnosing Stage IV HL. Conclusions Lymphoma is often misdiagnosed as TB, prolonging time to treatment and may adversely impact patient prognosis due to disease progression. Existing TB guidelines for smear-negative cases are not clear when to consider alternative diagnoses. In smear-negative TB, lymphoma should be considered as a differential and definitive diagnostic tests such as molecular testing and histological examination of biopsies should be considered earlier in the diagnostic work-up to prevent diagnostic delay.

A difficult case of Hodgkin lymphoma mimicking tuberculosis in a young female patient: A case report

“…Based on the symptoms, family history, and radiological images, the initial diagnosis was in favor of TB and the treatment began since the most common TB site is in the lung and its main feature on the X‐Ray chest image is cavitary lesions. 1 The points that support the clinical diagnosis of tuberculosis in our patient are clinical symptoms and radiological images that showed tuberculous cavities in the lung, her family history of tuberculosis, the country is endemic to tuberculosis and no studies are showing actual prevalence in the community, and lymphadenopathy was not present initially. After 2 months of quadruple TB treatment (isoniazid, rifampin, pyrazinamide, ethambutol); the clinical symptoms and radiological images continued to worsen and the sputum culture result was negative for TB so it is either multidrug‐resistant TB or it is not TB.…”

“…TB shares clinical manifestations with many diseases including HL, where one can mimic the other, making their diagnosis a challenge and leading to a misdiagnosis. 1 , 8 …”

“…The first CXR demonstrated cavitary pulmonary lesions and pleural effusion. Based on the symptoms, family history, and radiological images, the initial diagnosis was in favor of TB and the treatment began since the most common TB site is in the lung and its main feature on the X‐Ray chest image is cavitary lesions 1 . The points that support the clinical diagnosis of tuberculosis in our patient are clinical symptoms and radiological images that showed tuberculous cavities in the lung, her family history of tuberculosis, the country is endemic to tuberculosis and no studies are showing actual prevalence in the community, and lymphadenopathy was not present initially.…”

“…TB shares clinical manifestations with many diseases including HL, where one can mimic the other, making their diagnosis a challenge and leading to a misdiagnosis. 1,8 The relationship between HL and TB has been proven but it is difficult to distinguish due to several points; the first is that TB and HL present common B symptoms. Furthermore, the lesions may originate at sites where performing a biopsy is difficult.…”

“…Hodgkin lymphoma (HL) is a B‐cell lymphoma, representing 1% of all latest diagnosed tumors worldwide and 15% of lymphomas [85% of these are non‐Hodgkin lymphoma (NHL)]. 1 According to the last global data analysis, the incidence of HL is 0.98 per 100,000 people and is still on the rise, particularly among females, Asians, and young people. 2 The most common manifestation is asymptomatic lymphadenopathy in cervical, and supraclavicular.…”