Pulmonary involvement of Hodgkin’s disease is notuncommon, but there are few case reports of cavitarypulmonary Hodgkin’s disease mimicking as lung ab-scess or necrotizing pneumonia. In this report, we de-scribe a case of pulmonary Hodgkin’s lymphoma pre-senting as a large cavitary lesion with air-fluid levels inthe right lower lobe mimicking as lung abscess or necro-tizing pneumonia. The patient showed right lower tra-cheal and right hilar lymphadenopathy at the initial pre-sentation. The involvement of Hodgkin’s lymphoma inthe lung parenchyma and mediastinal nodes was con-firmed by histologic diagnosis.

Case Report

A 31-year-old man presented with cough and bloodtinged sputum. The initial chest radiography was doneoutside our hospital, and it had revealed airspace consol-idation in the right upper lobe. The chest CT demon-strated airspace consolidation in the right upper lobeand centrilobular nodules in the right middle lobe. Rightlower paratracheal and hilar lymphadenopathy were al-so seen. Although the sputum AFB was negative, active

pulmonary tuberculosis had been clinically suspected;thus, he had been previously treated with anti-Tb med-ication at another hospital for 8 months. However, therehad been no improvement, and so he was then trans-ferred to our hospital.

The cough and blood-tinged sputum continued and afever developed. The follow-up chest CT showed a new-ly appeared airspace consolidation in the right lowerlobe. He was hospitalized for further evaluation and un-derwent bronchoscopic examination. No endobronchiallesions were visualized. Transbronchial lung biopsy re-vealed nonspecific inflammation. No malignant cellswere seen on cytologic examination of the bronchialwashing, and bacterial organisms and fungi were notfound in subsequent cultures.

One month later, the follow-up contrast-enhanced CTdemonstrated a 5 cm sized cavitary mass containing anair-fluid level and small cavitary nodules in the rightlower lobe. A small amount of pleural effusion in theright side was newly noted. The right paratracheallymph nodes were increased in size (Figs. 1A-D).Drainage of the abscess pocket by bronchoscopy wastried; however, this was ineffective. Repeated broncho-scopic washing and cultures revealed no diagnosis. Hewas empirically treated with antibiotics for about 2months. However, the blood tinged sputum was moreaggravated and the high fever waxed and waned. Thefollow-up chest simple radiography and chest CT re-vealed the decreased size of cavity, but persistent exten-

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Hodgkin’s Lymphoma MimickingNecrotizing Pneumonia: Case Report1

Eun-Ah Park, M.D., Hyun Ju Lee, M.D., Jung-Gi Im, M.D.,Jin Mo Goo, M.D., Kun Young Lim, M.D., Chang Hyun Lee, M.D.

This study describes a case of pulmonary Hodgkin‘s lymphoma of the nodular scle-rosing type presenting as a large cavitary mass with air-fluid levels. We also conduct areview of the previous articles on pulmonary Hodgkin‘s lymphoma.

Index words : Hodgkin diseaseLung neoplasms, CT

1Department of Radiology and Clinical Research Institute, Seoul NationalUniversity HospitalReceived July 21, 2004 ; Accepted October 12, 2004Address reprint requests to : Hyun Ju Lee, M.D., Department of Radiologyand Clinical Research Institute, Seoul National University College ofMedicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea.Tel. 82-2-2072-2584 Fax. 82-2-743-6385E-mail: rosaceci@radiol.snu.ac.kr

sive consolidation was observed that mainly involvedthe right upper lobe and right lower lobe (Fig. 1E). Dueto the lack of definitive tissue diagnosis and uncon-trolled lung abscess, thoracotomy was advised. He un-derwent right upper lobectomy and right lower lobe su-perior segmentectomy (Fig. 1F). Additional right lowerparatrachal and subcarinal lymph node dissection wasalso performed. On the operative field, volume loss and

poor expansion due to diffuse consolidation of the rightupper lobe were noted. Consolidation was found in theright lower lobe’s superior segment and basal segments.The right middle lobe was relatively spared. On micro-scopic examination of the surgical specimens includingthe right upper lobectomy and right lower lobe superiorsegmentectomy specimens, Reed-Sternberg cells charac-teristic of Hodgkin’s disease were found (Fig. 1G).

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A B

C DFig. 1. A 31-year-old man presented with cough and blood tinged sputum.A. Chest simple radiograph shows a large cavitary mass in the right upper lung zone (arrow).B. Chest CT scan with the mediastinal window setting shows consolidation containing air-bronchograms (arrow) in the right upperlobe. A small amount of pleural effusion in the right side is also seen (black arrowheads). Note the enlarged right lower paratra-cheal lymph node (white arrowhead).C. Chest CT scan with the mediastinal window setting shows a 5 cm sized cavitary mass in the right lower lobe superior segment(arrow). The air-fluid level in the mass is seen (arrowhead).D. Chest CT scan with the lung window setting shows multiple satellite nodules adjacent to the main cavitary mass. Several satel-lite nodules had cavitation (arrowhead).

Pathologic examination of the mediastinal nodes re-vealed the same findings. The final histopathologic diag-nosis was Hodgkin’s lymphoma of the nodular scleros-ing type. Subsequent staging procedures including athorough physical examination, white blood cell countand bone marrow biopsy and a contrast-enhanced CT ofthe abdomen and pelvis were performed; the resultswere all negative. The patient underwent subsequentchemotherapy.

Discussion

Hodgkin’s disease usually presents as a localized dis-ease and it subsequently spreads to the contiguous lym-phoid structures. Ultimately, it disseminates to nonlym-phoid tissues with a potentially fatal outcome.Approximately half of patients with Hodgkin’s diseasepresent with adenopathy in the neck or supracalviculararea, and over 70 percent of patients present with super-

ficial lymph node enlargement. Approximate 60 percentof the patients present with mediastinal adenopathy. InHodgkin’s disease, axial lymph node involvement iscommon in contrast to non-Hodgkin’s lymphoma (1).

Mediastinal Hodgkin’s disease is common, and it iswell known to infiltrate the lung secondarily (2). Of allthe cases with Hodgkin’s disease, lung involvement hasbeen diagnosed in up to 20% at the initial diagnosis,40% during the clinical course of the disease and 60% atautopsy due to relapsing disease (3). Diederich et al (3)has reviewed the CT findings of pulmonary parenchy-mal lymphoma in 37 patients with recurrent or sec-ondary Hodgkin’s disease. In that study, the most com-mon CT findings were nodules or masses with the sizeranging from 2 to 100 mm. Consolidation (27%) and di-rect extension from the mediastinum (27%) were lessfrequently observed.

Primary pulmonary Hodgkin’s lymphomas are ex-tremely rare, and there have been only 61 cases report-

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E

F

G

Fig. 1. E. Last follow-up preoperative chest radiography showspersistent air space consolidation in the right lung.F. Magnified photography of right lower lobe superior segmen-tectomy specimen shows consolidation with several cavities.G. Photomicrograph of the resected lung specimen shows typi-cal Reed-Sternberg cells (arrows) that are characteristic ofHodgkin’s lymphoma.

ed since 1990 (4). The vast majority of primary pul-monary lymphomas are low grade B-cell non-Hodgkin’slymphomas (2). Primary pulmonary Hodgkin’s diseaseshows a bimodal age distribution, with the peak occur-rence at 21 to 30 years and 60 to 80 years, and this dis-ease affects women more often than men by a ratio of1.4 to 1 (2). The majority of patients are symptomatic atpresentation; common pulmonary symptoms include apersistent dry cough, dyspnea and hemoptysis (4).Radin et al (4) reviewed the findings on the chest radi-ographs of 61 cases of primary pulmonary Hodgkin’sdisease reported in the literature prior to 1990. Theyfound nodules or masses in 45 (74%) cases and pneu-monic consolidation in 13 cases (22%). The chest radi-ographs were normal in two cases (3%) and the radiolog-ic finding were not reported in one case. It is interestingthat upper lobe involvement was twice as common aslower lobe disease.

Hodgkin’s disease manifesting as a large cavitary lunglesion makes it difficult to distinguish it from the con-current infection due to anerobic bacteria, mycobacteri-um tuberculosis or fungi. Because cavitary change inHodgkin’s disease is very rare, the definite diagnosiscould be delayed and resection surgery is ultimately re-quired, as in our case. Furthermore, Hodgkin’s diseasemanifesting as cavitary lesions appears to be particularlyresistant to radiotherapy and it shows a poorer progno-sis (4). According to previous reports, the cavitation inHodgkin’s lymphoma is probably due to central is-chemic necrosis; this is presumably due to the rapid tu-mor growth and it tends to occur in large nodules andmasses. A cavity with air-fluid levels may be apparent

when there is communication between an adjacentbronchus and a necrotic tumor mass (5, 6). The inci-dence of cavitation was less than 10% in secondaryHodgkin’s lymphoma and cavitation was found in athird of primary Hodgkin’s lymphoma (3, 5, 7). Becausethe pulmonary parenchymal lesion is more predomi-nant than mediastinal lymphadenopathy, our case couldbe regarded as primary pulmonary Hodgkin lymphoma.However, the possibility that the mediastinal Hodgkinlymphoma infiltrated into the pulmonary parenchymacannot be completely excluded.

In summary, we report here on a very rare case of pul-monary Hodgkin’s lymphoma presenting as a large cavi-tary consolidation.

References

1. Freedman AS, Nadler LM. Malignancies of lymphoid cells. In:Isselbacher KJ, Braunwald E, eds. Harrison’s principles of internalmedicine, New York : McGraw-Hill, 1994:695-712

2. Cartier Y, Johkoh T, Honda O, Muller NL. Primary pulmonaryHodgkin’s disease: CT findings in three patients. Clin Radiol 1999;54:182-184

3. Diederich S, Link TM, Zuhlsdorf H, Steirmeyer E, Wormanns D,Heindel W, et al. Pulmonary manifestations of Hodgkin’s disease:radiographic and CT findings. Eur Radiol 2001;11:2295-2305

4. Radin AI. Primary pulmonary Hodgkin’s disease. Cancer 1990;65:550-563

5. Pickeril RG, Kaplan PD, Shively JG, Magovern GJ. Hodgkin’s lym-phoma presenting as lung abscess. Pa Med 1987;90:62-65

6. Jackson SA, Tung KT, Mead GM. Multiple cavitating pulmonarylesions in non-Hodgkin’s lymphoma. Clin Radiol 1994;49:883-885

7. Richardson GE, Longo DL. Multiple cavitating pulmonary nodulesin Hodgkin’s disease. Cancer 1991;68:930-933

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대한영상의학회지 2004;51:529-532

괴사성폐렴으로발현한호지킨폐림프종1

1서울대학교의과대학방사선과학교실, 서울대학교의학연구원방사선의학연구소

박은아·이현주·임정기·구진모·임근영·이창현

본 저자는 괴사성 폐렴, 혹은 폐농양과 흡사한 임상증상과 방사선학적 소견을 보이는 31세 남자의 결절 경화형 폐 호

즈킨 림프종 증례를 보고하고자 한다. 임상적으로 기침, 객혈, 발열을 호소하였고, 방사선소견에서 내부에 큰 공동화를

형성하며, 공기 액체층을 동반한 폐경화를 보였다. 주변으로 공동성 소결절과 소량의 흉막 삼출을 동반하였다.