Lymphocyte-Depleted Hodgkin’s Lymphoma in Coeliac Disease: A Diagnostic Challenge During the COVID-19 Pandemic

A 51-year-old woman presented with constitutional symptoms, polydipsia, early satiety, nausea, vomiting, and a pruritic vesicular rash. On physical examination, she was febrile, had low peripheral oxygen saturation in room air (91%), hepatomegaly, lower limb edema, and palpable cervical adenopathies. She was hospitalized for diagnostic investigations and treatment. An autoimmune panel was requested which was positive for anti-parietal gastric cell, anti-endomysial, and anti-tissue transglutaminase antibodies, raising the suspicion for coeliac disease (CD). Gastric and duodenal biopsies were not diagnostic for CD, which was compatible with necrolytic migratory erythema similar to the vesicular rash biopsy. Thoracic-abdomino-pelvic computed tomography scan and fludeoxyglucose F18-positron emission tomography identified supra- and infra-diaphragmatic hypermetabolic adenopathies, with hypermetabolic activity in the lungs, suggestive of pulmonary lymphomatous involvement. Fine-needle aspiration of one supraclavicular adenopathy was performed but was not enough for histological diagnosis. The patient’s respiratory insufficiency worsened and she died on day 63 of hospitalization. The final diagnosis was achieved on an anatomopathological autopsy that showed lymphocyte-depleted Hodgkin’s lymphoma. The association of CD with other lymphomas besides enteropathy-type T-cell lymphoma is not clear. There is no clear relationship between CD and lymphocyte-depleted Hodgkin’s lymphoma, which is the rarest subtype of classic Hodgkin’s lymphoma and, by itself, has a very poor prognosis. This case highlights the challenge in diagnosis and significant delay due to isolation associated with coronavirus disease 2019 infection.