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Year : 2014 | Volume : 2 | Issue : 1 | Page : 49 - 52  


Case Reports
Paediatric Hodgkin’s Lymphoma: A Study of 3 Cases

Kandukuri Mahesh Kumar1, V. Indira2, Sudhir Kumar Vujhini3

1Assistant Professor, 2Prof & HOD, 3Associate Professor, Department of Pathology, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad.

Abstract                      

Of all the pediatric malignancies, lymphomas account for about 10-15% of the cases with half of them diagnosed as Hodgkin’s lymphoma. Remarkably, this malignancy has a high cure rate with a 5-year survival rate approaching 95%. Hodgkin’s lymphoma has an overall incidence rate of 14 per 100,000 less than 15 years of age. It has a typical bimodal distribution with respect to age. In developed countries, the peak incidence is seen in young adults and the elderly. While, in developing countries the incidence is higher among children and young adults with a male preponderance. Histologically, mixed cellularity subtype of classical Hodgkin’s lymphoma occurs commonly in the children and in developing countries. We report three typical cases of classical Hodgkin’s lymphoma, mixed cellularity subtype with early-stage unfavorable disease presenting as a slightly painful right cervical mass and “B” symptoms. Erythrocyte sedimentation rate was elevated. Ultrasound neck scan suggested tuberculous lymphadenitis. Other laboratory and radiological findings were normal. Fine needle aspiration smears and histopathology helped in arriving at diagnosis of classical Hodgkin’s lymphoma, mixed cellularity subtype.

Keywords: Pediatric Hodgkin’s lymphoma; early-stage unfavorable disease; mixed cellularity subtype; B Symptoms

Corresponding Author: Dr. Kandukuri Mahesh Kumar, Assistant Professor, Department of Pathology, Malla Reddy Institute of Medical Sciences, Suraram , Hyderabad. Email: doctormaheshgoud@gmail.com

Introduction

Of all the pediatric malignancies, lymphomas account for about 10-15% of the cases [1] with half of them diagnosed as Hodgkin’s lymphoma. [2] Remarkably, this malignancy has a high cure rate with a 5-year survival rate approaching 95%. [1] Hodgkin’s lymphoma has an overall incidence rate of 14 per 100, 000 under 15 years of age. It has a typical bimodal distribution with respect to age. In developed countries, the peak incidence is seen in the young adults and elderly. While, in developing countries the incidence is higher among children and young adults with a male preponderance. Histologically, mixed cellularity subtype of classical Hodgkin’s lymphoma occurs commonly in the children and in developing countries. [3] We report a typical case of classical Hodgkin’s lymphoma, mixed cellularity subtype in a 10-year old girl with early-stage unfavorable disease presenting as a slightly painful right cervical mass and “B” symptoms.

 

Case Report

Case 1- A 7 – year- old girl presented with complaints of swelling in the left side of the neck since 5 months associated with pain, fever, evening rise of temperature, night sweats , dry cough , lethargy and weight loss. On taking detailed history from the mother, it was found that the patient’s father who is a chronic alcoholic had tuberculosis 2 years ago and took complete course of anti-tuberculosis therapy. Before coming to our hospital, patient is on anti- tuberculosis drugs since 5 months. Patient’s mother complains that the size of the swelling is same since occurrence even after treatment for 5 months. On examination, the child had a temperature of 38.7 ° C. Systemic examination showed no organomegaly. On local examination, the left neck mass measured 1 x 1 cms, firm, non-tender, and slightly mobile, with normal skin above the swelling. Laboratory investigations like complete blood picture and urine examination were within normal ranges. Erythrocyte sedimentation rate (ESR) was elevated.

Refer Table 1 for the laboratory findings.

Case 2 - A 9- year-old boy presented to us with complaints of right side painful neck swelling, lethargy, on & off fever, night sweats, pain in the swelling since 1 month. The child had a temperature of 38.3° C. Systemic examination showed no organomegaly. On local examination, the right neck mass measured 2.5 x 2 cms, was firm, non-tender, and slightly mobile, with normal skin above the swelling. Laboratory investigations like complete blood picture and urine examination were within normal ranges. Erythrocyte sedimentation rate (ESR) was elevated. Refer Table 1 for the laboratory findings.

Case 3 - A 11-year-old girl presented to a general practitioner with a 4-month history of swelling in the right neck region associated with pain, fever, night sweats, lethargy and weight loss since 2 months. Initially, the swelling was small and slightly painful. The child remained asymptomatic for few days with analgesics and antibiotics even though the size of the swelling was same. Symptoms recurred after 15 days of treatment with an increase in size of the swelling, for which the child came to our hospital. The child had a temperature of 39.2° C. Systemic examination showed no organomegaly. On local examination, the right neck mass measured 4 x 2.5 cms, was firm, non-tender, and slightly mobile, with normal skin above the swelling. Laboratory investigations like complete blood picture and urine examination were within normal ranges. Erythrocyte sedimentation rate (ESR) was elevated. Refer Table 1 for the laboratory findings.

Table 1: Laboratory findings

LABORATORY FINDINGS

COMPLETE BLOOD PICTURE

               CASE 1

 

CASE 2

 

CASE 3

Haemoglobin

12.4 gm.%            

11.2 gm %

11 .8 gm %

Total leukocyte count

10200/cu.mm

7400/cu.mm

9600/ cu.mm

Differential leukocyte count

Neutrophils                 62 %

Lymphocytes             30 %

Eosinophils                 05%

Monocytes                 03 %

Basophils                   00%

Neutrophils             66 %

Lymphocytes           28 %

Eosinophils               02 %

Monocytes               04%

Basophils                 00%

Neutrophils       58 %

Lymphocytes     33 %

Eosinophils         05 %

Monocytes         04 %

Basophils           00 %

Platelet count

2.9 lakhs /cu.mm

2.2 lakhs /cu.mm

3.2 lakhs /cu.mm

RBC morphology

Normocytic

Normochromic

Normocytic Normochromic

Normocytic Normochromic

SEROLOGY

 

 

HIV 1 and 2

Negative

Negative

Negative

HBsAg

Negative

Negative

Negative

OTHERS INVESTIGATIONS

 

 

ESR

58 mm/hr.

44 mm/hr

46 mm/hr

Mantoux test

Non-reactive

Non-reactive

Non-reactive

Urine examination

Normal

Normal

Normal

 

Ultrasound neck- Case 1 – Scan shows mild enlarged lymph node measuring 1.2 x 1 cms in the left posterior triangle of the neck suggesting tuberculous lymphadenitis.

Case 2 – Scan shows an enlarged lymph node measuring 2.5 x 2 cm in the right anterior triangle of the neck suggesting tuberculous lymphadenitis.

Case 3 - scan shows an enlarged lymph node measuring 3.9 x 2.6 x 1.5 cms in the right anterior triangle of the neck suggesting lympho-proliferative disorder. Refer Table 2 for the radiological findings.

Table 2: Radiological findings

RADIOLOGICAL FINDINGS

RADIOGRAPH

 

 

Chest

Normal

Normal

Normal

Abdomen & pelvis

Normal

Normal

Normal

ULTRASOUND SCAN

 

 

Neck

Suggestive of Tuberculous lymphadenitis

Suggestive of Tuberculous lymphadenitis

Possibility of Lympho-proliferative disorder

Abdomen and pelvis

Normal

Normal

Normal

 

Cytology – (All cases showed similar features) Cytosmears from fine needle aspiration of the neck masses were suggestive of lymphoid neoplasm, possibly Hodgkin’s lymphoma (Figure 1A and 1B).

The neck masses were surgically excised and biopsy specimens sent for Histopathological examination.

FIGURE 1 A

 

FIGURE 1 B

 

 

Figure 1: (A) Cytosmear shows small and large lymphocytes, few bi-nucleate cells against haemorrhagic background (Haematoxylin and Eosin, 40x) (B) Cytosmear shows a classical Reed-Sternberg cell with a bilobed nucleus, prominent eosinophilic nucleoli with perinuclear halo and abundant cytoplasm (Haematoxylin and Eosin, 100x)

Histopathological Findings

Gross examination: case 1 - Grossly, the specimen of excision biopsy was a single well-circumscribed lymph node mass measuring 1 x 1 cms (Figure 2A), cut section shows homogenous fleshy appearance (Figure 2B).

 

Figure 2: (A) Gross specimen of lymph node which is well-circumscribed showing slight nodularity at foci (B) Cut-section shows homogenous grey white fleshy appearance.

CASE 2 - Grossly, the specimen of excision biopsy was a single well-circumscribed lymph node mass measuring 2.5 x 2 cms (Figure 3A), cut section shows homogenous fleshy appearance (Figure 3B).