Case Presentation: A 47- year-old man with a history of hypothyroidism presented to the emergency room (ER) for the evaluation of generalized body weakness and jaundice of a week duration. There was also associated intense generalized pruritus of about 6 months; subjective weight loss, recurrent fevers, nausea and vomiting. Physical examination was significant for an ill-looking man with icteric sclera, bilateral pitting pedal edema up to the ankles and subsequently, enlarged bilateral inguinal lymph nodes.Laboratory investigation on presentation was significant for hemoglobin – 9.4mg/dl (N: 11.6-15.9mg/dl), platelets – 118,000/μL (N: 146,000-388,000/μL), creatinine – 1.5mg/dl (N: 0.7-1.3mg/dl), ferritin – 4164.5 ng/ml (N: 18-464 ng/ml), alkaline phosphatase – 371 IU/L (N: 34-104 IU/L), total bilirubin – 11.1 mg/dl (N: 0.2-1.2mg/dl), direct bilirubin – 7.1mg/dl (N: < 0.3mg/dl) and positive bilirubin on urine analysis. The Gastrointestinal team was consulted for further management and continued to be a part of the multidisciplinary team involved in the patient’s care. Further work up revealed elevated β2 microglobulin - 29.41 mg /L (N: <2.51 mg/L) and negative autoimmune panel, CA 19-9 levels, LKM antibodies, actin antibodies, carcinoembryonic antigen level and mitochondria antibodies. CT abdomen revealed hepatosplenomegaly with nonspecific gallbladder wall thickening while a NM hepatobiliary scan was suggestive of hepatocellular dysfunction and/or distal common bile duct obstruction. MRI MRCP revealed similar findings. A liver biopsy and lymph node biopsy subsequently showed positive results for classic Hodgkin’s lymphoma, nodular sclerosing sub-type (NSCHL). The patient unfortunately passed away on the 12th day of admission due to complications related to his disease.
Discussion: According to the Centers for Disease and Control Prevention, about 8389 cases of Hodgkin Lymphoma (HL) were reported in 2016, with an age adjusted range of 2.5 cases per 100,000. There is a slight male predominance however it is slightly more common in Whites and Blacks than in Hispanics. There is also a bimodal age of distribution with the highest incidences in the 3rd and 8th decade of life and the NSCHL accounts for about 70% of cases. HL typically presents with constitutional (“B”) symptoms- fever, night sweats, or weight loss in an estimated 40 % of individuals. Lymphadenopathy, especially in the neck and mediastinal mass are also typical presentations. Pruritus is also fairly common said to occur in about 10-15% of patients and may actually be a harbinger such as in the index case. Although liver symptoms and abnormalities have been documented as much rarer presentation, the co-existence of jaundice and intense pruritus as the main presenting complaints led to the initial thought of a gastrointestinal disease. Regardless, there is a need for Physicians to keep a broad list of differential diagnoses even in patients that may be considered atypical based on their demographics.
Conclusions: Our report highlights a case of NSCHL which was initially thought to be a cholecystitis versus gall bladder/ common bile duct disease. To the best of our knowledge, no similar cases of atypical presentation in the Hispanic population has been reported in literature. In patients presenting to the ER, a high index of suspicion and possible awareness of non-conventional presentations is required by primary care physicians who often serve as the first point of contact.