The incidence of skeletal Hodgkin's disease varies from 9–14% during the course of the disease with up to 30–50% at post mortem [1
]. Skeletal involvement may present in four different ways: POHL (either solitary or multifocal); simultaneously in osseous and non-osseous sites; or recurrence of disease at osseous sites. We consider that in order to make a diagnosis of POHL there should not be any signs or symptoms of systemic disease at the time of presentation or at the time of staging. Historically it was felt that primary Hodgkin's of the bone did not occur and that bony involvement was a feature of haematological dissemination of the disease, thereby implying a less favourable prognosis [2
]. Granger et al
] reported a 5 year survival of just 4.2% with 80% of deaths occurring within first 3 years. POHL must therefore be distinguished from systemic HD with diffuse bone marrow involvement (Ann Arbor IV, see table ), as it appears that POHL may have a better prognosis than systemic Hodgkin's with bony involvement [4
]. The most recent case reported in the literature regards a 51 year old female who presented with left hip pain and was subsequently lymphadenopathy in the cervical and inguninal nodes. She was staged as VIB. The question remains as to whether POHL has a better prognosis than HD with bony involvement [5
Staging of Lymphoma: Ann Arbor classification
There are thirty three clearly reported cases of primary osseous lymphoma at either single or multiple sites, in all ages, in the scientific literature since 1927. Table details these 32 cases as well as this current case. It does not include patients who presented with disease at non osseous and osseous sites, or those patients in whom hodgkins disease disseminated to the bone. At least 7 of these cases were reported prior to 1954 when CT, MRI and PET scanning was not available, so it cannot be stated for certain, whether these cases had any evidence of lymphadenopathy within the chest or abdomen. We are uncertain therefore, whether these are true cases of POHL.
A table of cases in the literature who presented with Hodgkin's lymphoma disease at single or multiple bony sites.
The two cases presented by Ostrowski et al
] were among 25 patients diagnosed with osseous Hodgkin's disease from a group of over 500 patients known to have had Hodgkin's lymphoma, at the Mayo clinic between 1927 and 1996. Five of the twenty five had POHL; three had disease at a single bony site and two had multifocal bony disease.
Gross et al
] presented two cases in adolescents (12 years and 17 years) who presented in a very similar pattern to ours. Both presented with back pain and raised inflammatory markers. Investigation revealed widespread osseous involvement. In the case of the 17 year old, treatment was delayed by a misdiagnosis of eosinophilic granuloma. The 12 year old is one of two other paediatric cases of primary multifocal osseous Hodgkin's lymphoma that we have identified. The other case was an 11 year old girl with disease in the thoracic spine, pelvis and left femur [1
There have been two paediatric cases identified by our literature review of patients with POHL at a single site. A case report by Citow JS et al
] of a 54 year old female, with back pain and spinal cord compression, thought to be secondary to tuberculosis. Only when antituberculous treatment failed, did re-examination and investigations reveal POHL as the cause.
Radiologically, bony lesions of Hodgkin's disease may be lytic, sclerotic or mixed. One study showed that 75% were lytic, 13.6% mixed and 11.4% mixed [3
]. When they involve the vertebral column, the disease can spread from one vertebral body to another across the intra-vertebral disc space and cause destruction of the disc [9
In all reported cases, the correct diagnosis was only reached after extensive and repeated investigations and review of the histology. The average time to diagnosis from initial presentation was 6–8 months. The most frequent misdiagnosis was osteomyelitis. Our case highlights the difficulties in diagnosing this rare form of Hodgkin's disease.
TB in England has increased by 25 per cent over the last 10 years. Most TB in England occurs among people in inner cities – two in every five cases are in London (see table ).
TB in England has increased by 25 per cent over the last 10 years. Most TB in England occurs among people in inner cities – two in every five cases are in London. Tuberculosis in the UK (2004 statistics) from global health facts.