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Case History

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Image not available. 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?

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Background

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Image not available. The differential diagnosis in a young woman is:

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  • malignancy;

  • tuberculosis;

  • sarcoidosis.

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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.

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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.

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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.

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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.

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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).

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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 ...

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