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  Table of Contents    
LETTERS TO EDITOR  
Year : 2014  |  Volume : 57  |  Issue : 4  |  Page : 656-658
Classical Hodgkin lymphoma with coexistant plasma cell neoplasm: A case report


1 Department of Laboratory Haematology & Molecular Genetics, TATA Medical Center, Kolkata, West Bengal, India
2 Department of Pathology, TATA Medical Center, Kolkata, West Bengal, India
3 Department of Hematology, TATA Medical Center, Kolkata, West Bengal, India

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Date of Web Publication11-Oct-2014
 

How to cite this article:
Arora N, Arun I, Chakrapani A, Nair R. Classical Hodgkin lymphoma with coexistant plasma cell neoplasm: A case report. Indian J Pathol Microbiol 2014;57:656-8

How to cite this URL:
Arora N, Arun I, Chakrapani A, Nair R. Classical Hodgkin lymphoma with coexistant plasma cell neoplasm: A case report. Indian J Pathol Microbiol [serial online] 2014 [cited 2019 Dec 13];57:656-8. Available from: http://www.ijpmonline.org/text.asp?2014/57/4/656/142726


Dear Editor,

Lymphomas are a diverse group of malignancies and include both Hodgkin and non-Hodgkin lymphoma (NHL). [1] Hodgkin lymphoma (HL) is not an uncommon tumor but HL with a coexistent plasma cell neoplasm is very rare. To the best of our knowledge only 17 co-existent cases have been described in the literature so far. [2],[3],[4] We report a similar case with a synchronous classical HL and a plasma-cell neoplasm.

A middle aged patient presented to us with 3 month history of fever, weakness and abdominal distension. Patient had already received 3 months anti-tuberculosis treatment (ATT) for suspected tuberculosis abscess without much improvement in the symptoms. Laboratory studies done at presentation showed hemoglobin of 10.4 g/dl, total leukocyte count of 2900/ cmm and platelet count of 107,000/cmm. Serum calcium levels were 7.4 mg/dl (8.5-10 mg/dl), LDH 527 u/l (<300 u/l) and total protein of 8.2 g/dl (6-8 g/dl). Albumin/globulin ratio (0.4) however was mildly deranged. Serum creatinine and blood urea nitrogen were normal. CT scan revealed generalized lymphadenopathy with predominant enlargement of the cervical and abdominal nodes. A skeletal imaging survey showed collapse of the C4/C5 vertebrae and this collapse was suspected to be due to infiltration by a lymphoproliferative disorder. Cervical lymph node biopsy showed nodular sclerosing type of classical HL [Figure 1]. Subsequently additional tests were done to evaluate for any other systemic illness including malignancy. Among these, serum protein electrophoresis showed a moderate M band. Immunofixation was notably abnormal and showed a lambda restricted IgG monoclonal protein. Beta-2 microglobulin (B2M) was elevated at 14.86 (0.81-2.19) mg/L. Bone marrow aspirate appeared reactive with 2% mature looking plasma cells. Bone marrow biopsy however showed a focus with large cells resembling mononuclear Hodgkin cells amongst polymorphous background of lymphocytes, eosinophils and plasma cells. These large mononuclear cells were positive for CD30, PAX5 and were negative for CD15, CD45 immunostains. The small lymphocytes in the background were predominantly CD3 positive T-cells. The plasmacytosis in the interstitium was originally interpreted as reactive but additional immunostains done because of abnormal laboratory findings, showed a CD138, CD56 positive, lambda light restricted neoplastic plasma cell population which constituted approximately 10% of the overall cellularity [Figure 2]. So a final diagnosis of a classical Hodgkin lymphoma involving bone marrow with a coexistent plasma cell neoplasm was made. Additional immunostaining done to check for the clonality of the plasma cells in the lymph node revealed a scanty polyclonal plasma cell population. The patient was subsequently treated as HL with adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy and is well off 4 months after the diagnosis was made.
Figure 1: Shows lymph node with small nodules composed of large mononuclear cells inflammatory cells and surrounded by fibrocollagenous bands (H&E, ×20). (Inset) The lacunar cells within these nodules express CD30 (immunoperoxidase)

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Figure 2: The bone marrow biopsy displays increased plasma cells highlighted by CD138 immunostain (×20)

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Simultaneous presentation of plasma cell neoplasm and HL without a prior history of irradiation or any chemotherapy is extremely rare. To the best of our knowledge, only 17 cases have been documented in the literature. Most of them were above 50 years (range: 17-78). HL is commonly diagnosed first followed by myeloma diagnosis (9 cases, interval of 2-192 months). Myeloma followed by a diagnosis of HL was seen in 4 cases where as simulataneous myeloma/ HL only in 5 cases. The HL subtypes include nodular sclerosis-HL (6 cases), mixed cellularity-HL (5 cases), lymphocyte depleted HL (1 case) and a case of nodular lymphocyte predominant HL. Plasma cell subtypes include myeloma (n = 14), solitary plasmacytoma (n = 3) and a nodal plasma cell neoplasm. Monoclonal component was seen only in 13 cases. [2],[3],[4]

Detection of bone marrow severe plasmacytosis in the background of HL can create diagnostic problems as reactive plasma cell in the bone marrow may be seen with HL. [5] So awareness of the existence of these unusual presentations and an astute clinician/pathologist could actually help identify this condition. In this particular case also the bone marrow biopsy was involved by HL and the neoplastic plasma cell constituted only 10% of the overall cellularity. So there was a diagnostic dilemma and without the help of additional laboratory findings such as protein electrophoresis, immunoelectrophoresis and immunohistochemistry, it would have been difficult to suspect and then diagnose a coexistant plasma cell neoplasm.

 
   References Top

1.
Arora N, Manipadam MT, Nair S. Frequency and distribution of lymphoma types in a tertiary care hospital in South India: Analysis of 5115 cases using the World Health Organization 2008 classification and comparison with world literature. Leuk Lymphoma 2013;54:1004-11.  Back to cited text no. 1
    
2.
Oliai BR, Zakowski MF, Lin O. Hodgkin's lymphoma associated with plasma cell neoplasia: Cytological features and review of the literature. Diagn Cytopathol 2005;33:181-6.  Back to cited text no. 2
    
3.
Huppmann AR, Liu ML, Nava VE. Concurrent diagnoses of Hodgkin lymphoma and biclonal myeloma in the bone marrow. Ann Diagn Pathol 2010;14:268-72.  Back to cited text no. 3
    
4.
Chandran R, Simon M, Spurgeon SE. Concurrent presentation of Hodgkin Lymphoma and multiple myeloma. Case Rep Hematol 2013;2013:398769.  Back to cited text no. 4
    
5.
Joshi A, Aqel NM. Hodgkin's disease of bone marrow masquerading as a heavy plasma cell infiltration and fibrosis. Br J Haematol 2003;122:343.  Back to cited text no. 5
    

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Correspondence Address:
Dr. Neeraj Arora
Department of Laboratory Haematology & Molecular Genetics, TATA Medical Center, Kolkata - 700 156, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.142726

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