Digital Ischemia as an Unusual Manifestation of Hodgkin's Lymphoma

Dystrophic Nails: An Unusual Clue to Recurrent Lymphoma

Nail changes are a well-known phenomenon in T-cell lymphoma but have not been reported as widely in B-cell lymphomas and Hodgkin lymphomas. We describe a patient with a history of diffuse large B-cell lymphoma in a background of nodular lymphocyte predominant Hodgkin lymphoma treated eight years prior who developed new nail changes that were noted on a routine surveillance visit. He had developed symptoms of painful fingertips that became white and required him to wear gloves even in warm weather, suggestive of Raynaud phenomenon. Due to a suspicion of a paraneoplastic phenomenon, a positron emission tomography-computed tomography was obtained, which showed fluorodeoxyglucose avid uptake involving the spleen and retroperitoneal, para-aortic, and right inguinal lymph nodes. Right inguinal lymph node biopsy was non-diagnostic and a splenectomy was performed. Pathology evaluation of the spleen revealed recurrent nodular lymphocyte-predominant Hodgkin lymphoma. Treatment was initiated with rituximab-based systemic therapy. The Beau lines grew out eventually with normal new nail growth and there was an improvement in Raynaud phenomenon after systemic treatment.

Digital Gangrene: An Unusual Manifestation of Non-Hodgkin Lymphoma

Background

Non-Hodgkin lymphomas (NHLs) comprise a group of haematologic malignancies with different histologic subtypes. The clinical picture varies from indolent to aggressive presentation and nodal (lymphadenopathy) to extranodal (central nervous system, gastrointestinal, cutaneous plaque, or ulcer) involvement. Digital gangrene is seldom reported. Here, we describe a patient with pain and blackening of all fingers and toes as presenting symptoms of NHL. Case Presentation. A 32-year-old male weaver had been smoking three to five cannabis-containing cigarettes daily for about ten years and methamphetamine four to five tablets daily for five years. He had no history of Raynaud's phenomenon, fever, cough, weight loss, skin rash, joint pain, and atherogenic or thrombogenic risk factors. We found normal blood pressure and absent peripheral pulses in arms and legs, dry gangrene of all fingers and toes, generalized lymphadenopathy, and hepatomegaly with ascites. The chest X-ray was normal, as were blood sugar, lipid profile, and hepatic and renal function. Rheumatoid factor, antinuclear and antiphospholipid antibodies, C-ANCA and P-ANCA, hepatitis B and C, and HIV were negative. CT abdomen revealed hepatosplenomegaly with multiple intra-abdominal lymphadenopathies. The peripheral angiogram showed 90-99% stenosis of radial and dorsalis pedis arteries with normal proximal vessels. Diagnosis of non-Hodgkin lymphoma was confirmed by histopathology of cervical lymph node (diffuse type), immunohistochemically subtyped as peripheral T cell lymphoma (not otherwise specified). The digital ischemia worsened despite cessation of cannabis and methamphetamine and starting CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) treatment, making amputation necessary.

Conclusion

We present, to our knowledge, the first report of peripheral T cell lymphoma, NOS presenting with gangrene in all digits complicated by methamphetamine and cannabis abuse. This uncommon vascular manifestation of non-Hodgkin lymphoma may cause a diagnostic dilemma and delayed initiation of treatment.