SUBDIAPHRAMATIC PRESENTATION OF HODGKIN ’ S LYMPHOMA WITH PERIPHERAL NEUROPATHY

A 27 years old, unmarried male day labour, hailing from Jhalkathi presented to us with the complains of anorexia, weight loss and gradual weakness of all limbs for 6 months. On examination, he had features of peripheral neuropathy, but other systemic examinations were unremarkable. He did not have any significant lymphadenopathy or hepatosplenomegaly.He was diagnosed as a case of Hodgkin’s Lymphoma, lymphocyte predominance, after diagnostic laparotomy followed by excisional biopsy from intraabdominal lymph node.Subdiaphramatic Hodgkin’s lymphoma is rarely occurs and may present in several ways. Peripheral neuropathy is one of these. We treated him with Doxorubicin, Bleomycin, Vinblastin and Dacarbazine with


Introduction:
The lymphoma arise as a malignant proliferation of lymphoid system and hence occur at any site where lymphoid tissue is present.Hodgkin's lymphoma is a rare disease involving primarily lymph nodes.A bimodal distribution of age at diagnosis has been observed, with one peak incidence occurring in patients in their 20's and the other in those in their 80's. 1 It is more common in males.It may represent as a final common response to diverse pathologic process such as viral infection, environmental or occupational exposures and a genetically determined host response. 1he histological hallmark of Hodgkin's lymphoma is the presence of Reed -Sternberg cells which are large malignant lymphoid cells of B cell origin. 2Hodgkin's disease has four histologic subtypes like lymphocyte predominant, nodular sclerosis, lymphocyte depletion and mixed cellularity. 3Lymphocyte predominant Hodgkin's disease is a rare variant where few R-S cells may be identified.After an accurate histologic diagnosis and staging , chemotherapy and radiotherapy is instituted according to stages.

Abstract:
A 27 years old, unmarried male day labour, hailing from Jhalkathi presented to us with the complains of anorexia, weight loss and gradual weakness of all limbs for 6 months.On examination, he had features of peripheral neuropathy, but other systemic examinations were unremarkable.He did not have any significant lymphadenopathy or hepatosplenomegaly.He was diagnosed as a case of Hodgkin's Lymphoma, lymphocyte predominance, after diagnostic laparotomy followed by excisional biopsy from intraabdominal lymph node.Subdiaphramatic Hodgkin's lymphoma is rarely occurs and may present in several ways.Peripheral neuropathy is one of these.We treated him with Doxorubicin, Bleomycin, Vinblastin and Dacarbazine with successful outcome.limbs for 6 months.He did not have any history of fever, jaundice, vomiting ,alteration of bowel habit or any drug intake.He is a non-smoker, non-diabetic and non-hypertensive daylabour.With these complains he contacted with a local doctor and did some investigations and treated with some vitamins without any fruitful improvement.On examination, he was anaemic,non-icteric and all vital signs were within normal limit.He did not have any lymphadenopathy or hepatosplenomagaly.But on examination of nervous system, there were features of peripheral neuropathy suggested by wasting and absence of jerks in both lower limbs ,though fine touch, proprioception and vibration were intact.Rest of the systemic examinations revealed no abnormalities.
Chest X-ray and Urine routine examination was normal.Mantoux test,HBs Ag and Anti HIV were J MEDICINE 2008; 9 : 62-63 .negative.USG of whole abdomen showed peripancreatic and para-aortic lymphadenopathy.FNAC was done from para-aortic node and it suggested non-specific lymphadenitis.Finally diagnostic laparotomy was done and excisional biopsy was taken, which revealed Hodgkin's Lymphoma ; Lymphocyte predominant type.After confirmation of diagnosis treatment with Doxorubicin,Bleomycin,Vinblastin and Dacarbazine(ABVD) was started with good response.

Discussion:
Hodgkin's disease, a distinct malignant disorder of the lymphatic system that primarily affects the lymph nodes , serves as a paradigm of the successful evaluation of modern oncologic concepts.The management of Hodgkin's disease provides a multidisciplinary challenge, from an accurate diagnosis to a comprehensive staging evaluation and appropriate treatment recommendation.In contrast to the increasing incidence of Non-Hodgkin's Lymphoma, the annual incidence of Hodgkin's lymphoma remain stable over the past several decades. 4The diagnosis of Hodgkin's disease requires expert haematopathologic interpretation of a properly processed lymph node specimen.The Reed-Sternberg cell is the diagnostic tumour cell that must be identified within the appropriate cellular milieu of lymphocytes, eosinophils and histiocytes. 3Hodgkin's disease is unique pathologically because the tumour cells compose a minority of the cell population, whereas normal inflammatory cells are the major cell component.
Hodgkin's disease is a lymph node based malignancy and uniquely consists of lymphadenopathy in predictable clinical locations.More than 80% patients present with lymphadenopathy above the diaphragm, less than 10 to 20 % present with lymphadenopathy limited to regions below the diaphragm. 3We have to give special attention to the presence or absence of disease associated symptoms, which may occur in up to one third patients and include fever, night sweats, weight loss , pruritus and less commonly pain in involved region after ingestion of alcohol. 3,5Besides that some unusual presentation may be found like cutaneous disorders such as erythema nodosum and icthyosiform atrophy,paraneoplastic cerebellar degeneration and other distinct effects on the Central Nervous System. 6,7Peripheral neuropathy is one of that via which patient presented to us.The physical examination should carefully determine the location and size of all palpable lymph nodes.An inspection of Waldayer's ring, detection of hepatomegaly or splenomegaly and evaluation of the cardiac and respiratory status is important.After doing routine investigations ,lymph node biopsy, imaging studies and bone marrow biopsy should be done.But Staging laparotomy is the most definitive method for diagnosing infradiaphragmatic Hodgkin's Disease. 8er the past three decades, advances in radiation therapy and the development of effective combination chemotherapy have resulted in the cure of more than 75% of all newly diagnosed patients with Hodgkin's Disease.All patients regardless of staging should be treated with a curative intent.
1. Post Graduate Trainee, Department of Medicine,Dhaka Medical College Hospital.2. Assistant Registrar, Department of Medicine (White),Dhaka Medical College Hospital.3. Assistant Professor, Department of Medicine, Sylhet MAG Osmani Medical College.4. Associate Professor, Department of Medicine,Dhaka Medical College.