Hodgkin lymphoma masquerading as tuberculosis in a young chronic smoker

Hodgkin lymphomas are malignant hemato-lymphoid neoplasms involving lymph nodes and extra-nodal sites. Bone marrow infiltration at diagnosis is uncommon, occurring in approximately 10 % cases. Such infiltration, when present, is usually focal and often associated with extensive disease, systemic symptoms, cytopenias and unfavorable histology. In the unusual event of the absence of significant peripheral lymphadenopathy, these lymphoma-related B-symptoms may easily masquerade as an infectious illness. A 30-year-old male was initially administered inappropriate anti-tubercular chemotherapy in a primary care setting for a presumptive impression of pulmonary tuberculosis. On re-evaluation due to unresponsiveness to the drugs, bulky mediastinal lymphadenopathy was detected. However, his axillary lymph node aspirate revealed epithelioid cell granulomas further confounding the picture. The correct diagnosis of Hodgkin lymphoma was finally established when a bone marrow biopsy (for fever and pancytopenia) revealed the typical neoplastic Reed Sternberg cells that were confirmed immunohistochemically. The case highlights the necessity of an early bone marrow examination in patients with unexplained fever and peripheral blood cytopenias. Physicians in tropical third-world countries with resource constraints and high disease burdens need to strike a fine balance between maintaining a high index of suspicion for tuberculosis yet being wary of the risk of missing lymphoma in such patients.