The chest radiograph demonstrating cardiomegaly and severe widening of the mediastinum (figure 1) is from a 55-year-old lady who presented with several months of breathlessness. Her ECG revealed Mobtiz type II second-degree heart block.
A 2-year history of pruritus was noted. CT scan revealed mediastinal lymphadenopathy.
Transthoracic ECG showed thickening of the atrial septum consistent with an infiltrative process. It extended through the tricuspid valve and into the right ventricular outflow tract (figure 2, upper panel). The infiltration was also seen to encase the aorta (figure 2, upper panel).
Biopsy of the mediastinal nodes yielded a histological diagnosis of nodular sclerosing Hodgkin's disease. Due to concerns relating to the possibility of cardiac rupture, treatment was initiated in the form of prednisolone 50 mg/m2 daily for 11 days prior to adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy.
Six months later, following eight cycles of ABVD chemotherapy, repeat ECG has shown remarkable regression of the Hodgkin's disease (fig 2, lower panel).
- Autopsy series show that cardiac invasion by non-Hodgkin's lymphomas is as high as 25%,1 whereas cardiac involvement by Hodgkin's disease is distinctly rare.2
- This case is more unusual in that the cardiac involvement by Hodgkin's disease has caused heart block.
- Pruritus is a feature in >25% of patients presenting with Hodgkin's disease.3 Earlier consideration of this may have avoided the ensuing cardiac complications.