case_images: PMC9078817_01
case_images: 18F-FDG PET/CT performed at initial presentation showing hypermetabolic involvement of the spleen and lymph nodes above and below the diaphragm, as well as small, 18F-FDG-avid pulmonary nodules and focal skeleton/bone marrow hypermetabolic involvement.
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case_images: fig1
case_images: Additionally, the patient performed a 18F fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) which revealed extensive hypermetabolic involvement of the spleen (with a maximum standardized uptake value, SUV max, of 16.7) and lymph nodes above (cervical, supraclavicular and mediastinal lymphadenopathy) and below the diaphragm (paraaortic, celiac, hepatic hilar, and peripancreatic); additionally, there was evidence of small, 18F-FDG-avid pulmonary nodules and focal skeleton/bone marrow hypermetabolic involvement (Figure 1).
case_images: 18F-FDG PET/CT performed four months after MTX discontinuation, showing a reduction of the hypermetabolic activity of spleen and lymph nodes, and a spontaneous resolution of the hypermetabolic involvement of lungs and bone marrow.
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case_images: Four months after MTX discontinuation, a new PET/CT scan was performed, showing a decrease in size and metabolic activity of supra and infradiaphragmatic lymphadenopathy, a reduction of the hypermetabolic activity in the spleen (SUX max of 9.5), and a spontaneous resolution of the hypermetabolic involvement of the lungs and bone marrow (Figure 2).
case_images: 18F-FDG PET/CT performed 15 months after MTX withdrawal with an increased hypermetabolic activity in the spleen and a new hypermetabolic lesion involving the L4 vertebral body, consistent with progressive disease.
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case_images: Histopathological examination of splenectomy specimen. Infiltration of the splenic tissue by large pleomorphic neoplastic cells resembling HRS cells: (a) H&E stain, 100x magnification; b) H&E stain, 200x magnification]. These cells were positive for CD30 (c) and EBER (d).
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case_images: Histopathological analysis revealed multiple parenchymatous nodules composed by numerous Hodgkin and Reed-Sternberg (HRS) cells positive for CD30 and CD15, with dim expression of PAX5, and negative for CD45, CD20, CD10, and ALK; these cells were also positive for EBV-encoded RNA (EBER) (Figure 4).