A 20‐year‐old previously healthy man presented with 1 month of lower back pain. He noted a 30‐pound weight loss, night sweats, fatigue, and bleeding from the gums over the same time period. He noted no trauma to the back, and he did not use drugs. On presentation, he was febrile with palpable painless cervical, axillary, and inguinal lymphadenopathy. The remainder of his examination was normal. He had a platelet count of 13 and a microcytic anemia. An MRI of the lumbar spine revealed an L3 lytic lesion that was associated with soft‐tissue swelling and a moth‐eaten lesion in the iliac bone. A biopsy of the iliac bone, inguinal lymph node and bone marrow were inconclusive. EVB and CMV titers were negative, as was his HIV Test. He had a positive ANA level, anti‐Smith antibody, and low complements. He was treated as having Kikuchi's disease, a rare subtype of SLE. However, he subsequently developed a nasopharyngeal mass that compromised his airway, requiring tracheostomy. Resection of the mass revealed nodular sclerosing Hodgkin's disease.
Low back pain is a common problem encountered by the hospitalist. Though most cases are due to degenerative or overuse injuries, it is important to employ a methodical approach in constructing the differential diagnosis. This is especially important in the presence of red‐flag signs and symptoms. Our patient's systemic symptoms of fatigue, weight loss, and lymphadenopathy increased the probability of a nondegenerative cause of the lower back pain, prompting early imaging and subsequent diagnostic tests. Hodgkin lymphoma is a malignant neoplasm with a bimodal distribution. Presenting symptoms are vague and often mimic other hematological malignancies, lymphadenopathy from primary tumors, and autoimmune diseases such as lupus. Musculoskeletal pain and signs of obstruction may arise as a consequence of lymphadenopathy. Rarely, patients present with autoimmune disorders such as autoimmune hemolytic anemia, thrombocytopenia, or neutropenia. Our patient demonstrated atypical features including fever and night sweats, observed in less than twenty percent of the younger population with Hodgkin's lymphoma, where they are often always present. His initial evaluation also identified anemia and thrombocytopenia, suggesting bone marrow involvement. With inconclusive biopsies, hematological disturbances, and serology supporting SLE, the diagnosis of Hodgkin's lymphoma was delayed until Reed‐Stern berg cells were identified in the nasopharyngeal biopsy.
It is important to remember the varying clinical presentations of Hodgkin's lymphoma. Although clinicians are taught that patients with Hodgkin's lymphoma present with painless lymphadenopathy, a mediastinal mass, and Reed‐Sternberg cells, fewer than half will have mediastinal involvement, and fewer than 1% of obtained cells will have the Reed‐Stemberg morphology. Because of its variety of presentation, the hospitalist must have a high index of suspicion for Hodgkin's lymphoma.
L. Gonsette, none; S. Mistry, none.