Diffuse Variant of Nodular Lymphocyte-Predominant Hodgkin Lymphoma in A 39-Year-Old Female: A Rare Case Report from Syria

Abstract

Introduction: Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) represents a rare subtype of Hodgkin Lymphoma that constitutes approximately 5% of all HL cases, with an annual incidence of 1-2 per 1,000,000. Histological diagnosis requires detecting the lymphocyte-predominant (LP) cells, characterized by their popcorn-like contours and distinct immunophenotypic features, including the expression of the B cell surface marker CD20, with negative expression of CD15 and CD30, within a characteristic tumoral microenvironment. Case Presentation: A 39-year-old Syrian female was admitted to our hospital due to a painless, palpable mass in the left axilla, accompanied by no other symptoms. Three months earlier, the patient noticed the mass and visited an external clinic, where she received a ten-day course of antibiotics without experiencing any improvement. Physical examination revealed a firm, round mass devoid of signs of inflammation. An ultrasonography was performed and identified six enlarged lymph nodes in the left axilla displaying signs indicative of malignancy. These nodes were surgically excised, and the subsequent microscopic examination unveiled a biphasic nodular and diffuse proliferation of small lymphocytes, follicular dendritic cells, and epithelioid histiocytes, mixed with large distinct tumor cells recognized as LP cells, that are characterized by multilobulated nuclei with finely granular chromatin and prominent nucleoli. Immunohistochemical examination demonstrated positive expression for CD20 and CD45 in the LP cells, along with CD57 in the background cells, with negative expression for CD15, CD30, and BCL6, while CD10, CD3, BCL2, and Cyclin D1 markers yielded inconclusive results. Consequently, the final diagnosis was confirmed as NLPHL-Diffuse variant. Conclusion: In our manuscript, we presented a diagnostically challenging case of NLPHL diffuse variant in a middle-aged otherwise healthy woman. This case emphasizes on the importance of thorough microscopic examination with the use of immunostaining to make an accurate histopathological diagnosis and thus to provide the best possible medical care in similar cases.