INTRODUCTION: Hodgkin’s lymphoma has rarely been reported as an etiology for malignant intrinsic airway obstruction. Such lesions can be amenable to systemic chemotherapy as well as localized interventional therapies to restore patency to occluded airways. We report a case of relapsed Hodgkin’s lymphoma presenting with dyspnea, cough and stridor due to endobronchial obstruction.
CASE PRESENTATION: A 28 year-old male presented to the Emergency Department complaining of progressive dyspnea and cough. On physical exam, he was noted to have stridor. The patient had a history of Hodgkin’s lymphoma, initially diagnosed eight months prior after he presented with an enlarged supraclavicular lymph node. Diagnosis was confirmed via excisional biopsy, and he underwent six cycles of chemotherapy, the last cycle completed three months prior to presentation. Computed tomography (CT) of the neck and chest done on admission revealed a necrotic paratracheal mass invading and encasing the distal trachea, limiting airway patency, with the smallest diameter measuring 4 mm, approximately 1 cm above the carina. Additionally, there was tumor invasion and near complete occlusion of the proximal right mainstem bronchus. He was admitted to the intensive care unit for airway monitoring and initiated on inhaled heliox, inhaled bronchodilators and systemic corticosteroids. He subsequently underwent flexible fiberoptic bronchoscopy followed by intubation of the left mainstem bronchus given concern for impending airway obstruction. Bronchoscopy revealed a polypoid lesion causing near complete occlusion of the distal trachea. Biopsies of this lesion were obtained, which revealed necrotic tissue with scant atypical cells. He remained intubated for seven days while undergoing systemic chemotherapy for relapsed Hodgkin’s lymphoma. He responded well with a documented decrease in size of the airway obstruction on both repeat CT of the chest and via flexible fiberoptic bronchoscopy. The patient was subsequently extubated, without recurrence of his presenting symptoms, and he is currently continuing salvage chemotherapy. He has been referred for palliative photodynamic therapy (PDT) and endobronchial Y-stent placement.
DISCUSSIONS: Hilar and mediastinal lymphadenopathy is a common presentation of Hodgkin’s lymphoma. The incidence of Hodgkin’s lymphoma presenting as an endobronchial mass with stridor is exceedingly rare, as most cases of endobronchial Hodgkin’s lymphoma have been reported on postmortem findings. Malignant tracheobronchial lesions can present with a wide variety of nonspecific respiratory symptoms including cough, hemoptysis, dyspnea, wheezing, chest pain and stridor. Endobronchial obstruction due to Hodgkin’s is usually treated with a combination of chemotherapy, radiation and surgery. Surgical options that have been described in the literature to treat endobronchial malignancy include laser therapy with neodymium:yttrium-aluminum garnet laser (Nd:YAG), PDT, and rigid bronchoscopy with mechanical stent placement.
CONCLUSION: Critical airway obstruction due to endobronchial Hodgkin’s lymphoma is exceedingly rare, but it should be in the differential for stridor. Securing the airway and maintaining its patency via intubation or other palliative measures is paramount in order to ensure that the underlying pathology can be treated. We successfully treated the obstruction with selective mainstem intubation, systemic chemotherapy and corticosteroids; however he may eventually require interventional maneuvers such as PDT and endobronchial stent plancement.
DISCLOSURE: Jaime Betancourt, No Financial Disclosure Information; No Product/Research Disclosure Information