|Year : 2015 | Volume
| Issue : 2 | Page : 87-88
A case report of primary Hodgkin's disease of bone marrow
B. M. S. Lamba, Vikas T Talreja, V Sudeep, Sakshi Mittal
Department of Medicine, Dr. Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
|Date of Web Publication||14-Jul-2015|
Dr. Vikas T Talreja
SFS Flat No. 886/gh-13, Paschim Vihar, New Delhi - 110 087
Hodgkin's disease (HD) is a malignant neoplasm of the lymphoid tissues. It arises almost invariably in a single node or chain of nodes. Extranodal disease can be primary or can result from the spread of primary nodal disease to these sites. Primary bone marrow HD is very rare. Here, we present the case of an elderly male, who presented with primary HD of bone marrow.
Keywords: Hodgkin lymphoma, elderely, bone marrow
|How to cite this article:|
Lamba B, Talreja VT, Sudeep V, Mittal S. A case report of primary Hodgkin's disease of bone marrow. Sahel Med J 2015;18:87-8
| Introduction|| |
Hodgkin's disease (HD) is primarily a malignant neoplasm involving proliferation of cells native to the lymphoid tissues, that is, lymphocytes, histiocytes, and their precursors.  It invariably arises in lymph node. Extranodal lesions in HD may develop and spread to virtually any organ system - lung, liver, bone, bone marrow, etc.  It is important to determine whether extranodal involvement represents a primary manifestation or dissemination of systemic disease, which has a poorer prognosis.  Primary extranodal presentation including bone and bone marrow involvement is very rare, occurring in <0.25% of patients. ,,, Here, we describe the case of an elderly male, who presented with primary HD of bone marrow.
| Case Report|| |
A 70-year-old man presented to us with chief complaints of pain epigastrium, vomiting, anorexia, and facial puffiness for 15 days. There was history of malaise and lassitude. No history of blood transfusion, bleeding from any site, bone pains, fever, or similar history in sibling was available. On physical examination, the patient was conscious, oriented with pulse rate: 100/min, blood pressure: 100/60 mmHg, and temperature 37°C. Patient was pale, anicteric with no peripheral lymphadenopathy. There was minimal pedal edema with normal jugular venous pressure and no bony tenderness. Systemic examination was also inconclusive. Laboratory investigations revealed hemoglobin: 3.2 g%, total leukocyte count: 6900/mm 3 , differential leukocyte count: N70L28E1B1, erythrocyte sedimentation rate: 22 mm, platelet count: 2.58 lacs/mm 3 , P/S: Normocytic normochromic red blood cells (RBCs) with mild anisocytosis and few microcytic, hypochromic cells and ovalocytes and platelets were adequate, retic count: 0.1%, mean corpuscular volume: 97.9 fl, mean corpuscular hemoglobin: 35.7 pg, mean corpuscular hemoglobin concentration: 36.5%, serum (S.) bilirubin: 0.7 mg%, alanine aminotransferase: 42 IU/l, alkaline phosphatase: 241 IU/l, S. proteins: Total - 6.2 g% and albumin - 3.9 g%, blood urea: 24 mg%, S. creatinine: 0.7 mg%, S. Na + : 135 meq/l, S. K + : 4.2 meq/l, S. Ca 2+ : 9.1 mg%, S. phosphorus: 3.3 mg%, urine routine and microscopy and myalgic encephalomyelitis: Nicotinamide adenine dinucleotide (NAD), electrocardiography: NAD, chest X-ray: NAD, ultrasonography abdomen showed no organomegaly or lymphadenopathy. Computed tomography chest and abdomen did not reveal any lymphadenopathy or bone lesions. Conventional X-rays of the axial skeleton and long bones were normal. Bone marrow aspiration was done, but the sample was dilute and therefore the report was inconclusive. Then patient's bone marrow biopsy was done. This showed bony trabeculae with closed marrow spaces. The marrow was infiltrated by nodules forming mixed population of cells - small lymphocytes, neutrophils, and eosinophils along with few plasma cells and histiocytes. Many atypical lymphocytes, 2-3 times the size of lymphocytes with high nuclear-cytoplasmic ratio, an irregular nuclear margin, and clumped chromatin was also seen. Occasional typical binucleate Reed-Sternberg cells More Details with prominent eosinophilic nucleoli were also seen. An area of hemorrhage and necrosis was also present. Thus, the diagnosis of HD was made.
| Discussion|| |
Hodgkin's disease involving bone and bone marrow is uncommon. ,,, Osseous involvement occurs in 5-20% of patients and bone marrow involvement in 5-32% of patients during the course of illness.  Osseous lesions of HD, most commonly arise by hematogenous dissemination to marrow resulting in stage IV disease. Less commonly, extrinsic pressure from involved lymph nodes leads to focal sclerosis of the adjacent vertebra. Localized multifocal skeletal HD, perhaps arises de novo within the marrow and local proliferation results in cortical erosion and lysis.  Patients with osseous HD present with bone pain and type B symptoms.  Most common site of involvement is the axial and proximal appendicular skeleton.  The various sites of involvement in decreasing order of frequency are dorso lumbar spine, pelvis, ribs, femur, and sternum.  The lesions are predominantly osteolytic with ill-defined borders but may rarely be sclerotic or mixed. ,, In patients with HD, bone marrow involvement is rare at presentation  and when present, is, usually, focal in nature. Magnetic resonance imaging is the best imaging modality to demonstrate bone marrow involvement.
Our patient presented with nonspecific type B symptoms. All investigations in his case were nonconclusive except normocytic normochromic anemia with low reticulocyte count. Bone marrow biopsy was, therefore, planned to find out the cause of anemia as the aspiration was inconclusive. In the present case, bone marrow biopsy revealed the cause to be infiltration of bone marrow by malignant lymphoid cells characteristic of HD. Sometimes, patients of HD show a non-specific reaction of marrow against extramedullary lymphogranulomatosis, and this is called as "tumor myeopathy" and it depends primarily on the progress of the disease.  In most cases in areas of bone marrow infiltration, bone is also altered due to stimulation of mesenchymal activities in bone by tumor and is not the consequence of direct destruction by the tumor.  In our patient, despite bone marrow involvement, bone was unaltered, which is quite rare.
| Conclusion|| |
All patients who present with anemia with normal RBC morphology and inconclusive bone marrow aspiration should also be investigated for lymphoma.
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