CRA65 A CURIOUS CASE OF MEDIASTINAL LYMPHOMA PRESENTING WITH ERYTHEMA MULTIFORME AND EXUDATIVE PLEURAL EFFUSION

Syuhada Zakaria1, Ag Zarif Aminuddin Bin Ag Damit2, Larry Ellee Nyanti2 3, Meryl Grace Lansing2 3, Subramaniam Ponnuvelu2, Nai-Chien Huan2, Shan Min Lo2, Hema Yamini Ramarmuty2, Kunji Kannan Sivaraman Kannan2
1 Department of Internal Medicine, Hospital Queen Elizabeth, Kota Kinabalu, Kota Kinabalu, Sabah, Malaysia
2 Department of Respiratory Medicine, Hospital Queen Elizabeth, Kota Kinabalu, Sabah, Malaysia.
3 Medical Department, Faculty of Medicine and Health Sciences, University Malaysia Sabah, Kota Kinabalu, Malaysia.

Introduction

Erythema multiforme is an immune-mediated reaction involving the skin and sometimes the mucosa, which may be triggered by multiple stimuli, most commonly infections, medications, inflammatory bowel disease and malignancy. Hodgkin Lymphoma is the most common lymphoma in adolescents and young adults, and rarely presents with pleural effusion or erythema multiforme. We describe a case of Hodgkin lymphoma presenting with pleural effusion and erythema multiforme.

Case Report

A 32-year-old female non-smoker with no comorbidities presented to our center with cough, exertional dyspnea and constitutional symptoms for two weeks. Physical examination revealed stony dullness and reduced air entry over the right thorax and a rash over the torso.  Initial chest radiograph revealed homogenous opacity over the right lung and bedside thoracic ultrasonography confirmed pleural effusion. Pleural fluid analysis revealed an exudative with low adenosine deaminase levels. Pleuroscopy showed a yellowish nodule at the costophrenic angle, however, pleural biopsy was inconclusive. Computed tomography pulmonary angiography (CTPA) was performed and revealed a 7.7x4.3x9.3 cm anterior mediastinal mass with sternal erosion and multiple mediastinal and axillary lymphadenopathy. Ultrasound-guided biopsy of the mediastinal mass showed Reed-Sternberg cells suggestive of Hodgkin Lymphoma. Skin biopsy confirmed erythema multiforme, which was attributed to paraneoplastic cutaneous manifestation of Hodgkin Lymphoma. She was subsequently referred to the Haematology unit for chemotherapy.

Discussion and Conclusion

In the setting of lymphoma, pleural effusion may arise from pleural infiltration of lymphoma or lymphatic obstruction The diagnostic yield of pleural biopsy in diagnosing Hodgkin Lymphoma is unknown, and inconclusive pleural biopsies warrant further evaluation with CT imaging. While erythema multiforme is associated with malignancy, it is rarely reported in Hodgkin Lymphoma. Clinicians should be alerted to this rare presentation of Hodgkin Lymphoma.