INTRODUCTION:Hodgkin’s disease arises within mediastinal lymph nodes and has a tendency to spread to contiguous areas. Pneumothoraces, unilateral or bilateral, and airway obstruction are documented in the literature as modes of presentation or complications of therapy and represent challenges before and during treatment.
CASE PRESENTATION:The patient is an athletic 18 year-old black male, who presented to the emergency department complaining of sudden onset of sharp chest pain, associated with shortness of breath. His review of systems was negative for fever, chills, night sweats or weight loss. His physical examination revealed mild tachycardia 103 bpm, oxygen saturation of 100% on room air, expiratory stridor with markedly decreased breath sounds over the left chest area and bilateral cervical, axillary and inguinal lymphadenopathy. Laboratory work up showed leukocytosis at 15.1, alkaline phosphatase at 181, a lactate dehydrogenase of 190. Initial chest x-ray showed a left-sided pneumothorax and likely mediatinal mass and a follow-up chest CT confirmed an approximately 30% pneumothorax and anterior, middle and superior mediastinal masses, with significant narrowing of the trachea above the carina. The patient’s condition began to deteriorate and he was transferred to the ICU. A supraclavicular mass was biopsied and left-sided chest tube was placed. The patient became more and more lethargic and was intubated for hypercarbic respiratory failure. Even with mechanical ventilation, he was very difficult to ventilate. An emergency bronchoscopy revealed a 3cm/2cm fungating mass protruding through the anterior wall of the trachea, resulting in an 80% obstruction of the lumen and deviation of the right bronchus. Just hours following intubation the lymph node biopsy results diagnosed Hodgkin’s lymphoma, of nodular sclerosing type. Chemotherapy was started immediately. Two days after initiation of treatment the patient self-extubated and was able to breathe well on his own. Four days later he developed a second spontaneous pneumothorax, this time on the right side. A repeat chest CT done 14 days later showed persistence of pneumothoraces with the anterior mediastinal mass this time only minimally compressing the trachea. A chest x-ray performed 22 days after diagnosis revealed residual pneumothoraces of 20% on the right and 40% on the left side which remained stable even after removal of the chest tubes. He was discharged home and continued on chemotherapy. Repeat chest x-rays showed the slow resolution of the pneumothoraces over 2 weeks. He has done well with the chemotherapy and plans are being made for mediastinal radiation.
DISCUSSIONS:The combination of high degree tracheal obstruction and spontaneous pneumothorax represents an unusual presentation for Hodgkin’s lymphoma. The cause of the initial pneumothorax was thought to be direct invasion of tumor into the lung parenchyma versus barotrauma secondary to airway compromise. There are a number of case reports of the developemnt of pneumothoraces after the initiation of chemotherpay in patients with Hodgkin’s lymphoma. In this patient, considering the presence of a tracheal mass, there was also concern forthe possibility of development of a tracheal fistula as a result of chemotherapy.
CONCLUSION:Hodgkin’s lymphoma can present with new onset shortness of breath caused by spontaneous pneumothorax and/or impingement of tumor on the upper airways. If not recognized in timely fashion it can cause respiratory failure leading to cardio-respiratory arrest and death.
DISCLOSURE:Corina Filip, No Financial Disclosure Information; No Product/Research Disclosure Information