Immune Thrombocytopenia at Diagnosis of Hodgkin Lymphoma

Background: Immune thrombocytopenia (IT) has rarely been found in patients with Hodgkin lymphoma (HL), as a paraneoplastic phenomenon or a simultaneous not related disease.

Case report: A 16-year-old boy was sent to our centre for the CT suspect of thoraco-abdominal lymphoma. Clinical examination revealed: obesity, petechiae and ecchymosis, no palpable lymphnodes, hepatosplenomegaly. Laboratory investigation showed thrombocytopenia (10 × 10³/mL) and elevated inflammatory markers. Viral serology and autoimmunity have ruled out secondary causes of thrombocytopenia. Bone marrow examination revealed no tumor cells. An abdominal mass biopsy was performed and complicated by uncontrolled bleeding and respiratory failure requiring admission in ICU, despite previous administration of intravenous immunoglobulin and platelet transfusion. The boy received intravenous steroids (3 grams in 3 days) with optimum raise of platelet count (204 × 10³/mL). Diagnosis was HL, nodular sclerosis type. Chemotherapy and radiotherapy were administered according to national protocol, and no other treatment was needed for thrombocytopenia. The boy is in complete remission, ten months after the end of treatment, with normal platelet count.

Discussion: Prevalence of IT associated with HL has been estimated as 0.2 – 1%. The relationship between the two entities could consider IT as a paraneoplastic disorder or as a simultaneous but not related disease, or finally an erroneous immune response to malignancy. In our case the non hyporegenerative nature of thrombocytopenia was suggested by the normal bone marrow analysis, the poor response to transfusion, the rapid rise of platelet count after administration of steroids and the absence of other clinical conditions that could explain thrombocytopenia, such as infections and lupus. This case reveals how thrombocytopenia complicated the normal HL diagnostic work up.