A 34-year-old woman presented with a dry cough for some weeks and feeling intermittently that her voice had changed. The only other symptom that she volunteered was that she had noticed increasing itching over the previous 6 months. On questioning she admitted to losing 6 kg in weight in the last few months without trying and that she woke up at night sweating two or three times a week. She had no other symptoms of note. She had no significant past medical history and took no regular medication. She lived with her husband and two sons aged 5 and 8 years. They had no pets. She did not smoke. On examination there were no abnormal signs; in particular, she was apyrexial, had no palpable lymph nodes and her chest was clear. Her blood tests, including a full blood count, urea, electrolytes, calcium and phosphate, and liver function tests, were all normal, apart from a mildly raised plasma viscosity. A chest X-ray showed mediastinal widening.
What is the most likely diagnosis and what further investigations should be arranged?
The differential diagnosis in a young woman is:
A computed tomography (CT) scan would be helpful in assessing the cause of the mediastinal widening and excluding the presence of a lung parenchymal abnormality that might be associated with tuberculosis.
In this patient the CT scan confirmed the presence of lymphadenopathy from the left lower-cervical region extending through the mediastinum to the subcarinal lymph nodes. The largest lymph node mass was 5 cm × 8 cm at the level of the aortic arch. There were no abnormalities in the lung parenchyma.
Lymphadenopathy this extensive is most likely to be due to malignancy. The most likely malignancy in a young woman with no significant past medical history and who is a non-smoker is a lymphoma. Drenching night sweats are a recognized symptom of lymphoma, as is itching, although the latter is relatively rare.
A mediastinal biopsy was performed. This showed nodular sclerosing Hodgkin lymphoma. Staging investigations were completed with a CT scan of the abdomen and pelvis and a bone marrow aspirate and trephine test. These showed no evidence of disease.
The presence of night sweats, weight loss of >10% of the body weight in the previous 6 months or Pel Ebstein fever are B symptoms, which have an adverse prognostic significance. It should be noted that itching does not constitute a B symptom. The disease is staged according to the Ann Arbor classification. She has stage IIB disease, i.e. disease confined to lymph nodes on one side of the diaphragm (see Table 27.1).
Combination chemotherapy is the treatment of choice in Hodgkin lymphoma for patients with B symptoms, bulky lymphadenopathy or stage III or IV disease, i.e. advanced disease. These patients ...