A 65-year-old man is brought to the emergency department due to chest pain. The patient has had fatigue, retrosternal heaviness, and a nonproductive cough for several weeks. Today, he developed severe chest pain after drinking a beer at a retirement party. The patient has no chronic medical conditions but has been taking diphenhydramine for the last month due to generalized pruritus. He does not smoke but drinks alcohol socially. Temperature is 36.5 C (97.7 F), blood pressure is 132/84 mm Hg, and pulse is 86/min. Physical examination shows clear lungs and normal heart sounds. ECG reveals sinus rhythm with no ST-segment or T-wave changes. Chest x-ray reveals a large, anterior mediastinal mass displacing the trachea. Laboratory results are as follows:
| Complete blood count | |
| Hemoglobin | 10.8 g/dL |
| Mean corpuscular volume | 92 µm3 |
| Platelets | 240,000/mm3 |
| Leukocytes | 11,000/mm3 |
| Neutrophils | 70% |
| Eosinophils | 10% |
| Lymphocytes | 18% |
| Monocytes | 2% |
| Serum lactate dehydrogenase | 820 U/L |
| Serum troponin I | normal |
Which of the following is the most likely diagnosis for this patient?
Hodgkin lymphoma | |
Epidemiology |
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Manifestations |
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Diagnosis |
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EBV = Epstein-Barr virus. | |
This patient with a large anterior mediastinal mass, pruritus, alcohol-associated pain, elevated lactate dehydrogenase (LDH), and eosinophilia likely has Hodgkin lymphoma (HL).
HL is a lymphoid neoplasm that most often affects those age 15-35 or >60. It generally develops in a single lymph node and spreads to contiguous nodes via the lymphatic and thoracic ducts. Although most patients have painless peripheral lymphadenopathy in the cervical/supraclavicular chains, approximately 50% have significant mediastinal lymphadenopathy. This can compress adjacent structures and cause a nonproductive cough, shortness of breath, and/or retrosternal pain.
Patients with HL occasionally have severe pain in areas of lymphadenopathy (eg, chest) following exposure to small quantities of alcohol (eg, drinking a beer). The etiology is unclear, but the pain may be due to alcohol-induced vasodilation within the lymph nodes, causing capsular distension. Patients also frequently have long-standing fatigue, B symptoms, and pruritus. Laboratory evaluation often reveals normocytic anemia, eosinophilia (tumor cells secrete cytokines that generate eosinophils), lymphopenia, and elevated LDH (associated with high tumor burden). Lymph node biopsy showing Reed-Sternberg cells is diagnostic.
(Choice A) Germ cell tumors can also cause an anterior mediastinal mass, compressive symptoms (eg, nonproductive cough), and elevated LDH levels. However, the tumors most often arise in individuals age 20-40 (vs 65), and eosinophilia is uncommon. In addition, pain does not typically worsen with exposure to alcohol, and pruritus is unexpected.
(Choice B) Histoplasmosis occasionally causes a mediastinal mass (eg, due to granuloma formation). However, most patients have pulmonary infiltrates, fever, and other systemic symptoms (eg, headache, myalgia). In addition, eosinophilia is uncommon, and there is often an antecedent history of exposure to bird (eg, chicken coop) or bat (eg, cave) droppings.
(Choice D) Sarcoidosis can present with chest pain, cough, anemia, and eosinophilia. However, it is usually characterized by hilar (vs mediastinal) lymphadenopathy, and most cases arise in young adults. ACE (vs LDH) is usually elevated.
(Choice E) Thymomas often cause an anterior mediastinal mass, and their growth can cause compressive symptoms (eg, nonproductive cough). However, eosinophilia is uncommon, and alcohol-associated pain and pruritus suggest HL. In addition, patients with thymoma often develop paraneoplastic myasthenia gravis.
Educational objective:
Hodgkin lymphoma is a common cause of a mediastinal mass that often presents with compressive symptoms (eg, cough, shortness of breath, retrosternal pain). Peripheral lymphadenopathy, B symptoms, pruritus, and alcohol-associated pain may also be present. Laboratory evaluation often reveals elevated serum lactate dehydrogenase and eosinophilia.