Atypical Presentation of Classical Hodgkin Lymphoma Mimicking Disseminated Infection or Metastatic Disease in a Young Female

Introduction

Classical Hodgkin lymphoma (cHL) is a B-cell lymphoid malignancy characterised by the presence of Hodgkin and Reed-Sternberg (HRS) cells within a reactive cellular milieu. It shows a bimodal age distribution and is most commonly observed in adolescents and young adults. While most cases present with painless peripheral lymphadenopathy, atypical, disseminated presentations complicating diagnosis are rare but clinically significant.1,2

Case Report

A 25-year-old female student presented with intermittent fever and unintentional weight loss over six months, progressing to abdominal distension and cervical/axillary swelling in the last two months. The initial complete blood count (CBC) was within normal limits. Empirical antibiotic therapy provided only transient relief, and symptoms recurred, prompting further evaluation.

Investigations

Her haemogram revealed haemoglobin 7.8 g/dL, white cell count: 55,400/µL with neutrophilic leucocytosis (Figure 1), platelets 203,000/µL. Peripheral blood smear demonstrated macrocytic anaemia, and elevated lactate dehydrogenase (LDH) 314.7 U/L. She also had prolonged prothrombin time and activated partial thromboplastin time (APTT). Abdominal ultrasound (USG) revealed hepatosplenomegaly and abdominal lymphadenopathy. Whole-body positron emission tomography (PET)–computed tomography (CT) scan revealed fluorodeoxyglucose (FDG)-avid lymphadenopathy in the cervical, mediastinal, abdominal, and pelvic regions; FDG-avid lesions in the liver, spleen, and right lung nodule; bilateral pleural effusions; and gross ascites (Figure 2).

Discussion

cHL is characterised by its unique tumour microenvironment, where few HRS cells orchestrate a rich inflammatory infiltrate.1-4 This case highlights the disease's potential for widespread organ involvement and clinical masquerade. The patient, presenting with persistent abdominal distension, was initially treated for disseminated tuberculosis. Histologically, the nodular sclerosis subtype — characterised by lacunar variant HRS cells and collagen bands — is most prevalent in young females.2,3,5 CD30 and CD15 positivity, along with weak PAX5 expression and loss of B-cell markers, are diagnostic immunophenotypic hallmarks.3

Checkpoint blockade using programmed cell death protein 1 (PD-1) inhibitors like nivolumab has revolutionised the management of relapsed/refractory cHL, and recent trials now demonstrate efficacy in first-line settings.1,4,6 This case supports these findings, showing early metabolic response and symptom relief. The patient has completed six cycles of chemo-immunotherapy and returned to her usual routine.