A 42-year-old male presents with complaints of fever, weight loss, and pruritus. On examination, a 2 cm firm lymph node of rubbery consistency is palpable in the right supraclavicular fossa, along with enlarged lymph nodes in the axillary region. The spleen is palpable 5 cm below the costal margin, and a chest X-ray reveals bilateral hilar and mediastinal lymphadenopathy. Based on these findings, what is the most likely diagnosis?
A. Carcinoma of the lung
B. Tuberculosis of lymph nodes
C. Cystic fibrosis
D. Hodgkin’s disease
E. Acute myeloid leukemia
Correct Answer: D. Hodgkin’s disease
Explanation:
The clinical features in this patient strongly suggest Hodgkin’s lymphoma, a type of lymphoid malignancy that typically presents with painless lymphadenopathy, systemic symptoms (e.g., fever, weight loss, pruritus), and sometimes organomegaly. Let’s analyze why Hodgkin’s disease is the most likely diagnosis:
- Key Findings Supporting Hodgkin’s Disease:
- Rubbery lymph nodes: Firm, non-tender, and rubbery lymph nodes are classic findings in Hodgkin’s lymphoma.
- Location of lymphadenopathy: The presence of supraclavicular lymphadenopathy and mediastinal lymphadenopathy on chest X-ray is characteristic of this disease.
- Systemic symptoms: The so-called “B symptoms” (fever, weight loss, and night sweats) are commonly seen in Hodgkin’s disease and are associated with a worse prognosis. The patient’s pruritus is another hallmark symptom of Hodgkin’s lymphoma.
- Splenomegaly: Hodgkin’s disease often involves the spleen, as seen in this patient.
- Differential Diagnosis:
While other conditions might mimic Hodgkin’s lymphoma, the overall clinical and radiologic picture aligns best with this diagnosis. Below is a discussion of the incorrect options:
Why Other Options Are Incorrect:
A. Carcinoma of the lung:
- While supraclavicular lymphadenopathy may suggest metastatic lung cancer, this patient has systemic symptoms and widespread lymphadenopathy, including in the axilla and mediastinum. Carcinoma of the lung is unlikely without respiratory symptoms (e.g., cough, hemoptysis) or a primary lung mass visible on imaging.
B. Tuberculosis of lymph nodes:
- Tuberculosis can cause lymphadenopathy, but it typically presents with caseating necrosis and constitutional symptoms such as night sweats and low-grade fever. This patient’s rubbery lymph nodes, hilar and mediastinal involvement, and pruritus favor Hodgkin’s lymphoma over TB.
C. Cystic fibrosis:
- Cystic fibrosis is a genetic disease characterized by pulmonary and gastrointestinal symptoms, such as chronic respiratory infections and malabsorption. Lymphadenopathy and splenomegaly are not typical findings in cystic fibrosis, making it an unlikely diagnosis.
E. Acute myeloid leukemia (AML):
- While AML can present with systemic symptoms and organomegaly, it typically manifests with bone marrow failure symptoms, such as anemia, thrombocytopenia, or infections. This patient’s localized and rubbery lymphadenopathy makes Hodgkin’s disease more likely.
Key Features of Hodgkin’s Disease:
- Age Distribution:
- Bimodal age distribution: Peaks in the 20s and again after 50 years.
- Lymphadenopathy:
- Most common initial presentation.
- Involves supraclavicular, cervical, and mediastinal nodes.
- Systemic Symptoms (B Symptoms):
- Fever: Intermittent or low-grade, often described as Pel-Ebstein fever (cyclical fevers).
- Weight loss: Unexplained loss of >10% of body weight.
- Pruritus: Often generalized, caused by cytokine release.
- Diagnostic Features:
- Lymph node biopsy: Confirms the diagnosis with the presence of Reed-Sternberg cells.
- Imaging studies: Chest X-ray or CT scan shows mediastinal involvement and other lymphadenopathy.
Management of Hodgkin’s Disease:
- Diagnosis:
- Excisional biopsy of the lymph node is essential to confirm the diagnosis.
- Staging using PET/CT scan and bone marrow biopsy to assess the extent of disease.
- Treatment:
- Chemotherapy (ABVD regimen): A combination of Adriamycin, Bleomycin, Vinblastine, and Dacarbazine.
- Radiation therapy: Often used in early-stage disease.
- Prognosis: Excellent with treatment, with 5-year survival rates exceeding 80%.
Conclusion:
The constellation of painless rubbery lymphadenopathy, systemic symptoms, and splenomegaly in this patient strongly suggests Hodgkin’s disease. A complete diagnostic workup, including a lymph node biopsy, is necessary to confirm the diagnosis and initiate curative treatment. Early recognition is critical, as Hodgkin’s lymphoma is one of the most treatable cancers when diagnosed early.