C40-09 A Diagnostic Dilemma: Hodgkin Lymphoma Masquerading as Sarcoidosis

Abstract Introduction Sarcoidosis is a granulomatous disorder that can affect any organ system but most commonly manifests in the lungs. Diagnosis can be challenging as imaging findings overlap with a multitude of other diseases to include infectious and neoplastic. Diagnosis thus centers on tissue biopsies demonstrating non-caseating granulomas and the exclusion of alternative etiologies. A well-documented overlap syndrome between sarcoidosis and lymphoma exists, termed sarcoidosis-lymphoma syndrome (SLS). We present a case of Hodgkin lymphoma that initially presented with clinical features strongly suggestive of sarcoidosis. Case Summary A 23-year-old female with no significant medical history was initially evaluated for intermittent pleuritic chest pain and persistent cough by her primary care physician. Plain radiographs at this time showed bilateral hilar and mediastinal lymphadenopathy. Chest computed tomography (CT) was notable for bulky mediastinal and hilar lymphadenopathy, reticulonodular infiltrates, and a right middle lobe consolidation with surrounding satellite nodules. She was referred to pulmonary for further evaluation, and bronchoscopy with endobronchial ultrasound was performed. The bronchoscopy was notable for a distinctive cobblestone appearance in the airways, extrinsic compression at all lobar bronchi branching within the right lung, and induration of sampled lymph nodes leading to technically challenging transbronchial needle aspiration (TBNA). Results of her TBNA and endobronchial biopsies were non-diagnostic. Positron emission tomography (PET) was obtained and revealed widespread avidity to include cervical, para-aortic and inguinal lymph nodes, as well as in the right middle lobe consolidation and thoracic through lumbar spine. A subsequent cervical lymph node biopsy was diagnostic for classic Hodgkin lymphoma, nodular sclerosis type, and she was initiated on chemotherapy. Discussion SLS describes the relationship between sarcoidosis and development of lymphoproliferative disease. There is a reported 5.5-to-11-fold increase in the rate of lymphomas in sarcoidosis patients, with sarcoidosis seen developing before, after, or alongside malignancy. Definitive diagnosis of sarcoidosis can be notoriously challenging due to vast overlap in clinical presentation with infections and malignancies. Long term management of sarcoidosis centers on chronic immunosuppression aimed at blunting the chronic immune system activation thought to underly the pathophysiology of sarcoidosis. This runs contrary to the management of conditions that can present in a similar manner to sarcoidosis, underscoring the importance of sarcoidosis as a diagnosis of exclusion before treatment is initiated. We report a case of classic Hodgkin lymphoma that initially exhibited strong clinical and radiographic features suggestive of stage IV sarcoidosis. The definitive diagnosis was established only after a cervical lymph node biopsy. This abstract is funded by: None