Non Hodgkin's lymphoma presenting with bone pain and no lymphadenopathy

Abstract

A 40-year-old female who was an ex-intravenous drug user on methadone presented to the Emergency department reporting all over body pain and was subsequently found to have a diagnosis of non-Hodgkin's B cell lymphoma in the absence of lymphadenopathy. She did not respond to chemotherapy and pain management was difficult. This case demonstrates three things. Firstly, clinicians should be aware that ex-or current intravenous drug users presenting with pain may have significant pathology. Secondly, pain management in patients on methadone can be difficult. Lastly, the case describes an atypical but recognised presentation of lymphoma with bone involvement but no lymphadenopathy. Case historyA 40-year-old female presented to the Emergency department reporting all over body pain that was aching in nature and maximal at her hip and shoulder joints. The pain was so severe that she reported difficulty with breathing and being unable to mobilise. There was associated reduced appetite. She had a past medical history of intravenous heroin use but she had not injected for 2½ years and on admission was taking 120ml Methadone daily. She was known to be hepatitis C antibody positive, had an ileostomy for severe chronic constipation and had previously been diagnosed with severe depression. She smoked 15 cigarettes a day, did not drink alcohol and was unemployed. Her symptoms were so disabling in the month leading up to her admission that her family had been doing her housework and shopping.