Is it Non-Hodgkin’s lymphoma or tubercular lymphadenitis: A diagnostic dilemma

Purpose: Non-Hodgkin’s lymphoma is the thirteenth most frequent cancer reported worldwide. Patients present with painless progressively enlarging lymph nodes with or without systemic symptoms including fever, night sweats, weight loss, pruritus and fatigue. Tuberculosis is endemic in lower and low middle-income countries. Tubercular lymphadenitis (TBLN) is the most common form of extra-pulmonary tuberculosis. TBLN is a non-tender chronic enlarged discrete or matted node presenting infrequently with fever. As both NHL and TB have overlapping presentation, patients are misdiagnosed. Patients can also have simultaneous TB and lymphoma mimicking or hiding each other resulting in missed diagnosis. Here, we report a case of oropharyngeal NHL with a diagnostic uncertainty of lymph nodes being tubercular or lymphomatous.

Methodology: A 60 year old male presented with epistaxis and bleeding from mouth with progressive painless swelling in right side of neck since six months. CECT showed oropharyngeal mass with multiple discrete cervical and axillary lymph nodes. Biopsy of oropharyngeal mass revealed NHL. Chemotherapy with R-CHOP was administered. On interim response assessment, oropharyngeal mass resolved completely but level IV and V cervical and axillary nodes had partial response. However, lung nodules appeared with moderate pleural and pericardial effusion. Mycobacterium tuberculosis was detected in sputum by CBNAAT with rifampicin sensitivity. Anti-tubercular treatment (ATT) was started. On completion of two months of ATT, he did not have any palpable cervical or axillary node.

Results: He completed ATT of six months following which residual nodes along with bilateral lung nodules, pleural and pericardial effusion resolved completely. After completion of ATT, there was no evidence of any disease on PET-CT. Currently the patient is disease free and on follow up.

Conclusions: There is an increased risk of acquiring TB in cancer. Similarities in the presentation of NHL and TB can lead to misdiagnosis. Co-existence of lymphoma and TB is possible but less reported and can delay the definite diagnosis. TBLN masquerading cancer can upstage the disease leading to change in staging, intent of treatment and management. Dissemination of TB as a result of immunosuppressive treatment can be fatal. One should be careful in classifying lymph nodes without histological evidence specially those at unusual site or when unexpected disease response is observed. In cases presenting with extra-nodal lymphoma with lymphadenopathy, biopsy from involved nodes should be done specially in endemic countries where the incidence of TB is very high.

References: 1. Armitage JO, Gascoyne RD, Lunning MA, Cavalli F. Non-Hodgkin lymphoma. The Lancet. 2017;390(10091):298-310.
2. Bray F, Ferlay J, Soerjomataram I, Siegel R, Torre L, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer J Clin. 2018;68(6):394-424.
3. Gandhare A, Mahashur A. Tuberculosis of the lymph nodes: Many facets, many hues. Astrocyte. 2017;4(2):80.