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  Indian J Med Microbiol
 

Figure 8: A 22-year-old male patient with newly diagnosed Hodgkin's lymphoma diagnosed from left supraclavicular lymph nodal biopsy underwent staging positron emission tomography/computed tomography (PET/CT) study. PET/CT scan revealed intensely fluoro-deoxy-glucose (FDG) avid multiple left supra and infra clavicular and right paratracheal mass, left lower paratracheal, subcarinal lymphnodes along with lymphomatous involvement of lower lobe of the right lung and also few FDG avid focal lesions in spleen (a) Diffuse homogenous marrow uptake of FDG was seen consistent with cytokine induced bone marrow hyperplasia. Subsequently he underwent bilateral iliac crest bone marrow biopsies that did not reveal marrow involvement. No calcification or necrosis was noted in any of the lymph nodes or spleen was noticed. Patient was not known to have any past history of tuberculosis. After four cycles of adriamycin (doxorubicin), bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy, he developed a cough with expectoration and fever with evening rise of temperature for 20 days, which was not revealed with conventional antibiotic therapy. Follow-up PET/CT revealed disappearance of metabolically active disease in left supra and infra clavicular lymph nodes and lower lobe of the right lung. However, intensely FDG avid paratracheal mass showing central necrosis was seen along with few subcarinal lymph nodes and a focus in spleen (b). New infiltrates with mild FDG uptake were noted in bilateral lung fields suggestive of infectious pathology. On the basis of patient's symptomatology and necrotic mediastinal lymph nodes along with bilateral lung infiltrates (c-e) tubercular pathology was suspected. Subsequently patient underwent guided biopsy of the necrotic mediastinal lymph node, which revealed caseation necrosis and granuloma formation and cultures revealed Mycobacterium Tuberculosis. Subsequently patient was started on anti-tuberculosis treatment with relief of symptoms and clinical improvement. Learning points in this case are that in a tuberculous endemic country like India, TB can always co-exist with lymphoma and should be suspected when the symptomatology along with necrotic mediastinal lymph nodes and lung filtrates are seen on interim PET/CT scan

Figure 8: A 22-year-old male patient with newly diagnosed Hodgkin's lymphoma diagnosed from left supraclavicular lymph nodal biopsy underwent staging positron emission tomography/computed tomography (PET/CT) study. PET/CT scan revealed intensely fluoro-deoxy-glucose (FDG) avid multiple left supra and infra clavicular and right paratracheal mass, left lower paratracheal, subcarinal lymphnodes along with lymphomatous involvement of lower lobe of the right lung and also few FDG avid focal lesions in spleen (a) Diffuse homogenous marrow uptake of FDG was seen consistent with cytokine induced bone marrow hyperplasia. Subsequently he underwent bilateral iliac crest bone marrow biopsies that did not reveal marrow involvement. No calcification or necrosis was noted in any of the lymph nodes or spleen was noticed. Patient was not known to have any past history of tuberculosis. After four cycles of adriamycin (doxorubicin), bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy, he developed a cough with expectoration and fever with evening rise of temperature for 20 days, which was not revealed with conventional antibiotic therapy. Follow-up PET/CT revealed disappearance of metabolically active disease in left supra and infra clavicular lymph nodes and lower lobe of the right lung. However, intensely FDG avid paratracheal mass showing central necrosis was seen along with few subcarinal lymph nodes and a focus in spleen (b). New infiltrates with mild FDG uptake were noted in bilateral lung fields suggestive of infectious pathology. On the basis of patient's symptomatology and necrotic mediastinal lymph nodes along with bilateral lung infiltrates (c-e) tubercular pathology was suspected. Subsequently patient underwent guided biopsy of the necrotic mediastinal lymph node, which revealed caseation necrosis and granuloma formation and cultures revealed Mycobacterium Tuberculosis. Subsequently patient was started on anti-tuberculosis treatment with relief of symptoms and clinical improvement. Learning points in this case are that in a tuberculous endemic country like India, TB can always co-exist with lymphoma and should be suspected when the symptomatology along with necrotic mediastinal lymph nodes and lung filtrates are seen on interim PET/CT scan