Heart and Lymph Nodes: A Love Story Gone Wrong

Introduction/Background/Significance: Hodgkin's lymphoma (HL) is a hematologic malignancy characterized by the presence of Reed-Sternberg cells and commonly presents with lymphadenopathy, B symptoms, and/or a mediastinal mass. Mediastinal involvement occurs frequently, particularly with nodular sclerosing subtype1, affecting approximately 60-80% of patients. Although mass effect is common, it is rare for HL to manifest as a pericardial effusion with impending cardiac tamponade. We present a unique case of a 26-year-old male whose initial symptoms of chest pain and cough led to the discovery of a large anterior mediastinal mass and pericardial effusion, ultimately diagnosed as classic Hodgkin's lymphoma.

Materials and Methods/Case Presentation/Objective: A 26-year-old male with no significant medical history presented with a three-month history of persistent cough and chest pain. He had previously sought care at an urgent care clinic, where he was diagnosed with upper respiratory infection (URI) and prescribed antibiotics and steroids without symptom improvement. He also reported an unintentional weight loss of 25 pounds but denied fever or night sweats. He was a non-smoker.

Upon hospital admission, a computed tomography (CT) scan of the chest revealed a 20 × 1.5 × 10.5 cm heterogeneous, multilobulated anterior mediastinal mass, accompanied by a moderate-sized left pleural effusion and a moderate-to-large pericardial effusion. Electrocardiogram (EKG) findings showed no acute ischemic changes. Transthoracic echocardiography (TTE) revealed a normal left ventricular ejection fraction (55–60%) but demonstrated a large pericardial effusion with early signs of tamponade physiology.

Results/Description/Main Outcome Measures: Urgent pericardiocentesis was performed, draining approximately 625cc of red-tinged pericardial fluid. Cytology was negative for malignant cells, revealing reactive mesothelial cells and immunoblasts. Due to the size and appearance of the mediastinal mass, a biopsy was performed, and histopathological examination confirmed classic Hodgkin's lymphoma, stage IIBE.

Immunochemotherapy regimen was initiated, consisting of nivolumab (a PD-1 checkpoint inhibitor), along with doxorubicin, vinblastine, and dacarbazine (AVD).

Conclusions: Hodgkin's lymphoma (HL) frequently presents with mediastinal masses but pericardial involvement is rare, occurring only in about 5% of cases and often goes unrecognized. Most pericardial effusions in HL are asymptomatic and incidentally detected on imaging. Symptomatic presentations, such as dyspnea, chest pain, or peripheral edema, are much less frequent and potentially overlooked.

Our case highlights a diagnostic challenge, as the initial presentation mimicked a benign respiratory condition, leading to a delay in identifying the underlying malignancy. Multimodal imaging, including CT and echocardiography, was critical in identifying the mass and evaluating the extent of pericardial involvement. Prompt pericardiocentesis not only relieved the tamponade effect but also provided valuable diagnostic material. Clinicians should maintain a broad differential diagnosis in such cases, as early recognition and prompt intervention can significantly alter the clinical trajectory.

Current treatment for HL involves combination chemotherapy, often augmented by immunotherapy in refractory or advanced cases. Nivolumab, a PD-1 inhibitor, has shown efficacy in relapsed or refractory HL and is increasingly being incorporated into frontline regimens. Early initiation of treatment may improve outcomes by rapidly reducing tumor burden and alleviating compressive symptoms.