Hodgkin Lymphoma Mimicking Osteomyelitis

Abstract

Hodgkin lymphoma with symptomatic osseous involvement can have a similar presentation to osteomyelitis. Common findings in symptoms, laboratory workup, and imaging can make it very difficult to distinguish between the two diseases. Excisional biopsy should be pursued if fine-needle biopsy is equivocal and suspicion of lymphoma is high. We report a case of a 40-year-old man who presented with a history of marine animal sting on his neck and later developed erythema in the area, chest pain, constitutional symptoms, adenopathy, and imaging classic for sternal osteomyelitis. Fortunately, initial biopsy prompted the possibility of lymphoma, and further workup was initiated, which confirmed Hodgkin lymphoma. This case is a good reminder that malignancies and infections can share many common features, and keeping a broad differential diagnosis can be lifesaving. Proper staging and risk stratification of Hodgkin lymphoma help determine the optimal treatment.

Keywords: Hodgkin lymphoma; Lymphoma; Osseous Hodgkin lymphoma; Osteomyelitis.

Fig. 1

T1-weighted magnetic resonance images of the sternum with and without contrast. a Extensive osteomyelitis of the manubrium and sternum body with an area of nonenhancement involving the left upper manubrium measuring 2.3 cm × 1.5 cm (arrow) concerning for necrotic bone. b Extensive phlegmon involving the left first through fourth intercostal muscles and medial left pectoralis major spanning 9 cm × 5 cm (arrow) with multiple small abscesses.

Fig. 2

Fludeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) from skull base to mid-thigh. a Multiple FDG-avid bilateral axillary lymph nodes are identified with the largest node on the right measuring 2.4 cm × 2.4 cm (arrow), most likely reactive to osteomyelitis or an inflammatory process of the sternum. b Repeat PET/CT 3 weeks later showed progression of disease in terms of an increase in number, FDG activity, and size of bilateral cervical and axillary lymphadenopathy (arrows) consistent with lymphoma.

Fig. 3

Pathology of the right axillary lymph node. a HE stains of the specimen at ×20 magnification demonstrating nodules of lymphocytes surrounded by fibrous bands, typical of classical Hodgkin lymphoma, nodular sclerosis variant. b Diagnostic Reed-Sternberg cell (green arrow) and numerous lacunar cells (black arrows) on a background of a mixed population of small lymphocytes. HE. ×400. c Immunohistochemistry revealed positive staining of large neoplastic cells for CD30. d Positive staining for CD15.