Hodgkin’s Disease Presenting with Osseous Involvement.

A 51-year-old Caucasian female with a past history of hypertension and rheumatoid arthritis presented with intermittent fevers and fatigue for one year and left hip pain for six months. During the month prior to presentation she noted temperatures to 102° F at home and was having difficulty bearing weight on her left hip. She denied any weight loss, skin rash, morning stiffness and pain or swelling in other joints. Treatment with NSAIDS and a course of steroids had provided minimal relief. Physical exam was remarkable for the presence of pallor, two 1.5 cm, firm, non tender, mobile lymph nodes in the left posterior superior cervical chain and one 3 cm tender, fixed lymph node in the left inguinal chain. She had limited range of motion with both active and passive movement of the left hip and the joint was tender to heel percussion. Her lab work was significant for a moderate anemia of chronic disease, thrombocytosis to 614,000/μl, alkaline phosphatase of 400 U/L, lactate dehydrogenase of 204 U/L, erythrocyte sedimentation rate of 95 and β2-microglobulin of 3.6 mg/L. Magnetic resonance imaging of bilateral hips showed an aggressive marrow replacing process in the left iliac bone that had eroded posteriorly into the adjoining gluteal musculature with multiple enlarged lymph nodes along the left pelvic sidewall and bilateral inguinal chains. PET/CT revealed increased tracer uptake in the left iliac bone, adjacent soft tissues and in multiple lymph nodes in the neck, medistinum and pelvis and the liver and spleen. Excisional biopsy of an enlarged left inguinal lymph node revealed infiltration by nodular tissue with thick fibrous bands and classic Reed-Sternberg cells which were positive for CD 15 and CD 30. The patient was diagnosed with stage IV B Hodgkin’s Disease. Planned treatment consisted of 8 cycles of ABVD, followed by consolidative radiation to the left iliac bone. Patients with Hodgkin’s disease usually present with painless lymphadenopathy typically in the cervical region. Although radiologically detectable bone involvement is not unusual in disseminated disease, osseous lesions are seldom the primary manifestations. Less than 20 cases of Hodgkin’s disease presenting with osseous involvement have been described. A majority of these are of the nodular sclerosing subtype and involve the axial skeleton, most commonly the vertebrae, femur, and iliac bones as was seen in our patient.