Hodgkin lymphoma (HL) is typically known for presenting as enlarged lymph nodes, but occasionally, it takes an unexpected turn, spreading to less common locations. In this report, we dive into a rare case of nodular sclerosing Hodgkin lymphoma, where the disease had aggressively spread, invading the liver and stomach—locations rarely associated with HL.

A 40-year-old woman came to the clinic with persistent back pain, trouble walking, and noticeable weight loss. At first, these symptoms seemed to point to a spinal issue, prompting an L4 kyphoplasty. However, things quickly worsened, and her condition began to deteriorate. A PET-CT scan soon revealed troubling results—multiple areas of hypermetabolic activity across her lymph nodes and bones, which were now lighting up with disease.

A biopsy of the inguinal lymph node confirmed the diagnosis: classical Hodgkin lymphoma, nodular sclerosing type. Treatment started with Brentuximab vedotin paired with the AVD regimen (Adriamycin, Vinblastine, and Dacarbazine), but complications arose. During therapy, she developed a painful perianal abscess, which needed surgical drainage. Yet the disease kept advancing. New imaging showed a more aggressive spread: multiple hypermetabolic lesions were found in the liver, and another was detected in the gastric fundus. Despite a clear endoscopy, which didn't show any visible abnormalities in the stomach, a liver biopsy confirmed what the team feared—Hodgkin lymphoma had infiltrated her liver. Her treatment continues with careful monitoring as the medical team adapts to these complications.

This case paints a picture of the diagnostic and treatment challenges that arise when Hodgkin lymphoma doesn't follow the expected path. Instead of typical lymphadenopathy, the disease made itself known through musculoskeletal pain and neurological issues, creating a complex clinical puzzle. The rare involvement of the liver and stomach emphasizes just how unpredictable the systemic spread of this disease can be. While hepatic involvement in HL is unusual, it's critical to confirm this through biopsy, as it can easily be mistaken for other liver-related conditions. Gastric involvement, though rare, must be kept in mind when dealing with extensive disease spread. Advanced imaging, particularly PET-CT, played a pivotal role in uncovering these unexpected sites of involvement, guiding the treatment plan.

This case is a testament to the importance of recognizing atypical presentations of Hodgkin lymphoma and the need for flexible, evolving treatment strategies. The use of Brentuximab vedotin in combination with AVD has shown promise, especially in complicated cases like this one, where the disease has spread far beyond the usual lymphatic system. Understanding HL's ability to infiltrate uncommon sites like the liver and stomach is essential for improving patient outcomes. This case reminds us of the disease's unpredictable nature and the need for vigilance in detecting and managing its spread to rare locations.