A 21-year-old construction worker readyed to his local physician with a 15-lb (675-kg) weight los throughout 4 weeks and a 2-week history of cough with blood-tinged sputum excitements to 39.

A 21-year-old construction worker readyed to his local physician with a 15-lb (675-kg) weight los throughout 4 weeks and a 2-week history of cough with blood-tinged sputum excitements to 39.4 [degrees] C, and night sweats. After the patient had been receiving oral erythromycin for 2 weeks without improvement, a chest radiograph activeed referral for further evaluation.

Physical Examination

Vital signs: temperature, 383 [degrees] C; beating [i]or[/i] throbbing of an artery 105 beats/min; respirations, 22/min; BP 110/70 mm Hg Chest: clear. Cardiac: normal. Abdomen: smooth nontender, liver and spleen not palpable. Lymph nodes: minimal supraclavicular adenopathy.

Laboratory Findings

Hematocrit, 30 percent; WBC 17000 (76 percent sectioned neutrophils, 4 percent band neutrophils, 13 percent lymphocyte 7 percent monocytes); platelets, 493000/[mu]l; erythrocyte sedimentation rate, 113/mm/hr; HIV, negative. Arterial children gas values (room air): pH 741; [Pcosub2] 36 mm Hg; [Posub2] 86 mm Hg Radiologic: chest radiographs (Fig 1) and chest comput tomographic (CT) scans (Fig 2) were obtained.

What is the principally likely diagnosis?

Diagnosis: Hodgkin's disease (nodular sclerosing type) stage IV

The posteroanterior and lateral chest radiographs (Fig 1) demonstrate superior mediastinal adenopathy in the azygous, aortopulmonary window, and para-aortic locations. There is a large central opacity, which reach forths from the right hilum into the right upper lobe. There are cavities within this opacity, and cavitary nodules are scattered from one extremity to the other of the right upper lobe. The CT appearance (Fig 2) confirms the plain-film findings and demonstrates anterior mediastinal and subcarinal adenopathy, as well as air bronchograms and necrosis within the dominant parenchymal lesion.

Hodgkin's disease commonly has intrathoracic manifestations at presentation, particularly with the nodular sclerosis subtype The neighborhood of anterior mediastinal adenopathy assists diagnosis because these nodes are many times spared in patients with sarcoidosis. huge mediastinal disease, defined as adenopathy involving more than a third of the thoracic diameter upon a standard radiograph, represents a special category of Hodgkin's disease. The port of large mediastinal nodes indicates the probable extension of tumor into the lung chest wall, or pericardium, oftentimes with an accompanying pleural or pericardial effusion.

Pulmonary parenchymal involvement may deduction from direct mediastinal extension or from lymphatic or hematogenous dissemination from distant sites or from foci of parenchymal lymphoid tissue, which make known as spontaneous disease. Nodal extension of lymphoma between the walls of the bronchovascular bundle occurs chiefly frequently and produces a coarse interstitial reticulonodular infiltrate. Involvement of the interlobular septa can bring into being Kerley lines. Erosion into the bronchial mucosa can end in airway obstruction with atelectasis and postobstructive or endogenous lipoid pneumonia. A plaque or polypoid mass may rarely be seen during bronchoscopy and sputum or bronchoalveolar lavage fluid may reveal malignant small cavitys Lymphomatous infiltration through the alveoli can bring into view a granulomatous consolidation that can give the appearance of pneumonia or military tuberculosis.

Hodgkin's disease of the lung may at hand radiographically as either solitary or multiple nodules and may simulate primary or metastatic cancer. Cavitation present itselfs in fewer than 1 percent of patients and may lay open iniitially or after treatment. The air of cavitary disease in a patient with known lymphoma requires the exclusion of infections, so as tuberculosis and fungal and bacterial infections, particularly through Staphylococcus and Nocardia organisms.

Tumor infiltration of the pleura has been observ at autopsy in approximately 30 percent of patients with Hodgkin's disease. Pleural effusions usually ensue from lymphatic obstruction secondary to mediastinal adenopathy and are characteristically unilateral and serous, although chylous and sanguineous effusions may offer Pneumothorax can develop and may be persistent and recurrent

Bone involvement can be bring to lighted radiographically in approximately 15 percent of patients and is usually a late manifestation of the disease, although bone pain may be the presenting complaint. principally patients with bone involvement have mixed blastic and lytic lesions. Destruction of the ribs, breastbone or vertebrae by direct invasion from contiguous lymph nodes typically ensues in focal lytic areas. fair osteoblastic lesions can be observ in the spine and give the appearance of ivory vertebrae. Occasionally, disease may start in the ribs or breastbone and invade the lungs secondarily.

While it is almost axiomatic that thoracic Hodgkin's disease not aways with adenopathy, there is a rare form of pulmonary Hodgkin's disease called primary pulmonary Hodgkin's disease, which is restricted to the parenchyma at presentation. This form in the greatest degree commonly presents as single or multiple nodules that have a predilection for the upper lobes. There is a higher incidence of bilateral and cavitary disease than with nodal Hodgkin's disease. In a new review, several patients with primary pulmonary Hodgkin's disease had a normal chest radiograph and came to medical attention for symptoms of bronchial obstruction. At bronchoscopy endobronchial lymphoma was build Cough was the chiefly common presenting complaint, and a third had B symptoms (fever night sweats, and weight loss) which correlated with a poor prognosis. Thoracotomy is usually required for diagnosis.

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