A 25-year-old Hispanic female presented to our hospital with a 2-day history of abdominal pain which began abruptly and was associated with fevers, chills as well as intermittent nonproductive cough which had been present since her last episode of pneumonia about 6 months ago. She was admitted to the ICU for management of septic shock and briefly required pressor support along with broad spectrum antibiotics. Past medical history was remarkable for Brill-Zinsser disease and cryptogenic organizing pneumonia (COP), both diagnosed 2 years ago. She had traveled to Mexico 2 months ago, and was treated for recurrent Typhus at that time. Hypotension improved however, she continued to have fever daily despite adequate treatment of her presumed pneumonia. A wide array of tests ensued to rule out infectious and autoimmune causes of her fever. Patient tested negative for HIV, TB, syphilis, Legionella, Chlamydia, Streptococcal pneumonia, Typhus and various other serologies. Tests of autoimmunity remained negative as well. Imaging revealed bulky lymphadenopathy in paratracheal, subcarinal, paraaortic lymph nodes and around bifurcation of aorta along with left pelvic and obturator lymph nodes. CT chest was concerning for recurrence of COP. Review of lung biopsy report from an outside hospital was consistent with COP. Patient eventually underwent an excisional lymph node biopsy. Histopathology and immunohistochemical stains identified Reed-Sternberg cells and thus a diagnosis of Hodgkin’s lymphoma was made. Oncology service was consulted and patient was initiated on appropriate chemotherapy with quick resolution of fevers.
Discussion:
Cryptogenic organizing pneumonia represents a kaleidoscope of morphologies and concepts, often confused with a series of conditions, among which the most feared are Hodgkin’s lymphoma and bronchoalveolar carcinoma. We present the case of a young female with previously known diagnoses of COP and Brill-Zinsser disease in the setting of new onset lymphadenopathy. The non-favorable evolution of her symptoms and the high index of suspicion of the conditions that may mimic the COP histopathological pattern, were the basis of our persistence in getting the real diagnosis.
Conclusions:
This case illustrates the importance of avoiding anchoring heuristic (Anchoring Heuristic, also known as focalism, refers to the human tendency to accept and rely on, the first piece of information received before making a decision). The assortment of previous illnesses that this patient presented with certainly caused a diagnostic conundrum. Good history taking and organized approach to her case ultimately helped in not only diagnosing Hodgkin’s lymphoma but also timely instatement of treatment for this highly curable condition.