A case of concomitant Hodgkin's lymphoma with tuberculosis
A 29 year old woman presented to the local hospital with complaints of breathlessness and cough with expectoration for duration of eight weeks. On examination she was found to have enlarged cervical lymph nodes. Excision biopsy of the nodes were done and were subjected to histopathological examination (HPE), which revealed features suggestive of tuberculosis (TB), and hence the patient was started on anti tuberculous therapy (ATT) (isoniazid, rifampicin, pyrazinamide and ethambutol). She came to our hospital as there was no alleviation in her symptoms and increase in size of her cervical nodes in spite of her strict adherence to ATT therapy. A CT scan of thorax revealed enlarged paratracheal, subcarinal and hilar lymph nodes. An endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA) of the enlarged nodes was done to reconfirm the diagnosis, HPE of which revealed a granulomatous inflammation. Though the tissue was negative for acid fast bacilli (AFB) on smear's test, she was continued on ATT due to the endemicity of TB in our country. One month later, her symptoms had subsided while her cervical nodes did not show any signs of regression. Her EBUS TBNA samples which were sent for AFB culture turned out to be positive. As her drug sensitivity patterns were not available at that point of time she was advised to continue the same ATT regimen. Three months later she returned to our hospital with complaints of cough, right sided chest pain and hemoptysis. A CT scan of her thorax was repeated, it showed an increase in the size of mediastinal nodes compared with her previous scan []. She was subjected to mediastinoscopy which revealed mediastinal nodes adherent to trachea and great vessels. HPE of the nodes revealed features consistent with Hodgkin's lymphoma, nodular sclerosing variant, along with necrotising granulomatous inflammation [Figures and ]. Immunohistochemistry confirmed the diagnosis [] and it was classified as stage 2 Hodgkin's lymphoma as per the Ann Arbor staging criteria. She was initiated on chemotherapy (adriamycin, bleomycin, vinblastine, dacarbazine) of six 6 cycles, followed by external beam radiotherapy on the linear accelerator, using 6 MV photons, a dose of 30 Gy in 15 fractions was delivered to the mediastinal tumour bed by image-guided radiation therapy (IGRT) technique. She was advised to continue her ATT for a duration of nine months. A positron emission tomography (PET) scan was done after the completion of chemo- radiotherapy that showed no lymph nodes. As she improved clinically no further workup was done.