Classical Hodgkin Lymphoma: A Case Study of a Female Adolescent Presenting with Systemic Symptoms and Microcytic Anaemia

Hodgkin lymphoma (HL) accounts for approximately seven percent of childhood malignancy. It should be suspected in a child with lymphadenopathy, systemic complaints and mediastinal mass. Differential diagnosis includes other malignant, infectious and inflammatory diseases.

A 12-year-old female, with a six-month background of 15 percent weight loss, night sweats and fatigue and a recent diagnosis of microcytic hypochromic anaemia (Hgb 8.2 g/dL), presented at our emergency department due to aggravated anaemia (Hgb 7.9 g/dL) after a 30-day trial of iron therapy. Respiratory, gastrointestinal and bleeding symptoms were denied. Dietary restrictions, sick contacts and family history of autoimmune diseases were excluded. On examination, she presented fever, pallor and no palpable peripheral lymphadenopathy or organomegaly. Initial laboratory results confirmed microcytic hypochromic anaemia refractory to iron therapy. Blast cells were not seen on blood film, nor other morphologic abnormalities except microcytosis and atypical lymphocytes. It was also apparent an increase of acute-phase reactants (ferritin 515.3ng/mL, ESR 118 mm/hour), without elevated faecal calprotectin. Abdominal ultrasound was normal, however chest radiography revealed a subtle mediastinal widening. CT scan displayed an anterior mediastinal conglomerate of lymph nodes (8.7 x 6.5 x 9 cm) and mild splenomegaly (12.6 cm). She was transferred to an oncology center and excisional biopsy revealed a classical HL. Bone marrow involvement was excluded on aspiration and biopsy and FDG-PET scan confirmed supra-diaphragmatic nodal involvement.

About three-quarters of paediatric HL cases display a mediastinal mass on chest radiograph at the time of presentation. Mediastinal widening should never be overlooked particularly in the setting of classic B symptoms (fever, night sweats and ≥10 percent loss within six months before diagnosis). It should also be noted that malignant diseases as HL can produce microcytic anaemia, which may be misinterpreted as iron deficiency. Prompt referral to an oncology center is mandatory for diagnosis, staging and management.