A diagnosed case of Classical Hodgkin Lymphoma presented with Vertigo

Dr Muhammad Saiful Islam

MD Phase A Resident (Haematology)

BSMMU

Case Scenario

• Mrs Protima rani, 45 years old female presented with fever for 2 and a half months which was high grade, intermittent and subsided after taking paracetamol. Fever was also associated with weakness, anorexia and swelling in front and back of the neck.
• On examination she looked ill, average body build, decubitus was on choice, Anemic, no cyanosis, jaundice, clubbing, oedema. Her temperature was 98.4 F, pulse 80 beats/min regular, BP 100/70 mmHg, thyroid gland was enlarged and enlarged posterior cervical chain lymph nodes.

Case Scenario (Contd.)

• Respiratory system , Cardiovascular system, Gastrointestinal system, Genitourinary system, Musculoskeletal system, Nervous system examination revealed no abnormality.

Investigations

• Complete Blood Count (04/03/2021)

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• Reticulocyte count- 0.98%
• Serum Ferritin – 7621. ng/mL
• Serum Iron – 248 U/L
• TIBC 122 mcg/dL
• TSAT 13%

Investigations (Contd.)

• Chest X ray P/A view- Normal
• USG of neck – Enlarged right lobe of thyroid gland

Multiple lymph nodes in both sides of neck

• USG of whole abdomen- Abdominal lymphadenopathy

Mild pelvic collection

• CT scan of abdomen with contrast- Multiple tiny hepatic cyst

Abdominal lymphadenopathy

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Lymph node histopathology

• Compatible with mixed cellularity classical Hodgkin lymphoma

Bone marrow & Trephine Imprint Examination Report

• Features are suggestive of myeloid hyperplasia and secondary reactive marrow, no lymphocytic infiltration is seen.
• Histopathology report- Reactive hyperplasic marrow.

Immunohistochemistry Report

• Immunohistochemistry (IH-489/21)

The neoplastic cells show following immuphenotypes

CD30: Positive (including golgi zone type staining)

CD15: Positive (including golgi zone type staining)

PAX5: Weakly positive

CD3: Negative

CD20: Negative

Management

• Finally, diagnosis was Classical Hodgkin Lymphoma (Mixed cellularity)

So, patient was selected for ABVD protocol containing

Inj Doxorubicin

Inj Bleomycin

Inj Vinblastin

Inj Dacarbazine

• After starting the chemotherapy the patient complained of vertigo.

Vertigo

• Vertigo is a symptom of illusory movement.
• Vertigo is a symptom, not a diagnosis. It arises because of asymmetry in the vestibular system due to damage to or dysfunction of the labyrinth, vestibular nerve, or central vestibular structures in the brainstem.

Types

• Vertigo may be divided into 2 types

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• Central
• Peripheral

Peripheral Vs. Central Vertigo

Causes of Peripheral Vertigo

• Benign paroxysmal positional vertigo
• Vestibular neuritis
• Herpes zoster oticus (Ramsay Hunt Syndrome)
• Meniere disease
• Labyrinthine concussion
• Perilymphatic fistula
• Semicircular canal dehiscence syndrome
• Acoustic neuroma
• Otitis media

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Causes of Central Vertigo

• Vestibular Migraine
• Brainstem ischemia
• Cerebellar infarction and haemorrhage
• Chiari malformation
• Multiple Sclerosis
• Episodic Ataxia type 2

Drugs causing Vertigo

Antibiotics – Aminoglycosides e.g. Gentamycin

Cytotoxics – Cisplatin, Carboplatin, Vincristine

Diuretics – Furosemide given intravenously after aminoglycosides

Analgesics- Aspirin

Others - Quinine

Clinical Features

• Vertigo is the predominant symptom of vestibular dysfunction. Patients often experience vertigo as an illusion of motion; some interpret this as self-motion, others as motion of the environment.
• The most common motion illusion is a spinning sensation.
• Nausea and vomiting are typical with acute vertigo.
• Postural and gait instability.

Clinical Features (Contd.)

• Other symptoms includes-
• Tilt illusion -A tilt illusion in which patients feel that they and their environment are tilted with respect to gravity.
• Drop attacks - Patients with drop attacks of vestibular origin often have a sensation of being pushed or pulled to the ground.
• Spatial disorientation - A fleeting spatial disorientation with rapid head turns often remains after the patient has recovered from an acute attack of vertigo.

Clinical Features (Contd.)

• Oscillopsia - A visual illusion of to-and-fro environmental motion and blurred vision whenever the head is in motion, is a manifestation of an impaired vestibuloocular reflex (VOR)
• Impaired balance without vertigo - This is a common manifestation of acute simultaneous bilateral vestibular loss such as that occurring with aminoglycoside antibiotic toxicity.

Examination

• The Dix-Hallpike maneuver is the standard clinical test for BPPV. The finding of classic rotatory nystagmus with latency and limited duration is considered pathognomonic.
• This test is performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45° to the right. After waiting approximately 20-30 seconds, the patient is returned to the sitting position. If no nystagmus is observed, the procedure is then repeated on the left side.

Diagnosing Vertigo

Management of Vertigo

Non Pharmacological

Pharmacological

Non-Pharmacological Management

• VESTIBULAR REHABILITATION

Vestibular rehabilitation (physical therapy) promotes recovery in patients with permanent unilateral or bilateral peripheral vestibular hypofunction

Pharmacological Management

• Three general classes of drugs can be used to suppress the vestibular system
• Antihistamines – meclizine, dimenhydrinate, diphenhydramine
• Benzodiazepines – diazepam, lorazepam, clonazepam, alprazolam
• Antiemetics- ondansetron , prochlorperazine, promethazine, metoclopramide, domperidone

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THANK YOU