April 2021 — Hematopathology
A 38-year-old man presented with chronic cough associated with leukocytosis. Cough persisted for two months with chest CT findings compatible with right upper lobe lung (RUL) abscess. IR guided aspiration of the purulent material was negative for bacterial, mycobacterial and fungal cultures. Cytology performed was negative for malignancy. As the patient remained unresponsive to antibiotics, the RUL was surgically resected and the H/E stained and IHC slides showed the following:
What is the most likely diagnosis?
- Necrotizing sarcoidosis
- Hodgkin's lymphoma
- Fungal infection
- Lymphomatoid granulomatosis
The correct answer is ...
The correct answer is: Hodgkins lymphoma.
Hodgkin's lymphoma: Classic Reed-Sternberg (RS) cells are typically present within mixed inflammatory background, including small T- and B-cells, eosinophils, neutrophils, histiocytes, and plasma cells. RS cells are usually CD30 and CD15 positive, and CD20 negative (2/3) or CD20 weak-positive (1/3).
Lymphomatoid granulomatosis: Atypical lymphoid cells may resemble Hodgkin's-Reed Sternberg cells. Angiocentric distribution of these cells is a key feature of this condition. Atypical lymphoid cells are usually CD20 strongly positive.
Fungal infection: Fungal microorganisms may be visible on H&E or special fungal stains like Grocott’s methenamine silver (GMS) stain.
Necrotizing sarcoidosis: Typically has necrotizing granulomas that involve pulmonary vessels.
- Connors JM, Cozen W, Steidl C, Carbone A, Hoppe RT, Flechtner HH, Bartlett NL. Hodgkin lymphoma. Nat Rev Dis Primers. 2020 Jul 23;6(1):61. doi: 10.1038/s41572-020-0189-6. PMID: 32703953.
- Guermazi A, Brice P, de Kerviler E E, Fermé C, Hennequin C, Meignin V, Frija J. Extranodal Hodgkin disease: spectrum of disease. Radiographics. 2001 Jan-Feb;21(1):161-79. doi: 10.1148/radiographics.21.1.g01ja02161. PMID: 11158651.
Ameya Patil, M.B.B.S.
Resident, Anatomic and Clinical Pathology
April Chiu, M.D.
Associate Professor of Laboratory Medicine and Pathology
Mayo Clinic College of Medicine and Science