Cleveland Clinic Journal of MedicineUnilateral Green Pleural Effusion in a 22-year-old Woman

A Clinical Puzzle of Unilateral Pleural Effusion in Hodgkin Lymphoma

A 22-year-old medical student’s gradual onset of dyspnea led to the discovery of a unilateral pleural effusion, which upon thorough investigation, was diagnosed as symptomatic of classic Hodgkin lymphoma. The necessity for a systematic approach to pleural effusion evaluation, using both diagnostic and therapeutic procedures to establish and manage underlying malignancies efficiently, is paramount.

Key Points:

• Patient Presentation: A 22-year-old woman with a history of iron deficiency anemia and gastroesophageal reflux disease presented with progressive dyspnea, fatigue, weight loss, night sweats, and palpitations, initially mistaken for stress-related symptoms.
• Initial Assessments: Vital signs showed tachycardia, fever, and reduced oxygen saturation; physical examination revealed pallor, reduced breath sounds in the right hemithorax, and bilateral axillary lymphadenopathy.
• Laboratory Findings: Elevated white blood cell count and C-reactive protein levels suggested an inflammatory process, with normal liver and renal function.
• Imaging Results: Chest radiography and CT scans revealed unilateral right pleural effusion, bulky mediastinal masses, and bilateral axillary lymphadenopathy, indicative of significant thoracic pathology.
• Diagnostic Procedures: Thoracentesis extracted green-hued, lymphocytic, exudative pleural fluid, which lacked infectious agents, pointing towards a non-infectious etiology.
• Cytopathology Results: Analysis of pleural fluid showed atypical lymphocytes, raising suspicions of a hematopoietic malignancy.
• Biopsy Confirmation: Excisional lymph node biopsy confirmed the diagnosis of lymphocyte-rich Hodgkin lymphoma, characterized by distinctive Reed-Sternberg cells.
• Advanced Staging: PET scans diagnosed the patient with stage IV classic Hodgkin lymphoma due to extensive nodal involvement above and below the diaphragm and extranodal involvement.
• Treatment Approach: Initiation of a chemotherapy regimen including doxorubicin, vinblastine, dacarbazine, and brentuximab, which led to symptom resolution and discharge with outpatient follow-up.
• Pleural Effusion Insights: Pleural effusions in Hodgkin lymphoma typically present as exudative and lymphocytic, with a range of appearances from serous to bloody, highlighting the diverse manifestations of lymphomas.

“The excisional lymph node biopsy, while invasive, remains the gold standard for diagnosing lymphomas, as it allows for a comprehensive examination of the lymph node architecture.”

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