Working Diagnosis:
Stage IV Nodular Sclerosis Classic Hodgkin Lymphoma with osseous involvement of thoracic spine

Treatment:
Treatment with standard ABVD chemotherapy (adriamycin, bleomycin, vinblastine, dacarbazine) for 6 cycles with repeat PET/CT after 2 cycles. Tramadol for daily pain, hydrocodone for breakthrough pain. Abstain from playing pickleball while receiving early treatment to avoid compression fracture at the diseased vertebrae.

Outcome:
His International Prognostic Score is 2 indicating 80% five-year freedom from progression and 91% overall survival. After only his first cycle of chemotherapy, he reported a significant decrease in back pain and no longer required any pain reliever.
During his 2nd cycle, he was able to perform light volleying on the pickleball courts with much less back pain than before. PET/CT after 2 cycles of chemotherapy showed resolution of hypermetabolic activity. During his 4th cycle, he was able to perform competitive play again but with restricted playing time. After completing full treatment, the back pain has resolved and he has returned to full and unrestricted competitive play. He plans to participate in the US Open Pickleball Championships in Naples, FL this spring. He will be monitored with a PET/CT every 6 months for 2 years. He is very excited about playing competitive pickleball again without the suffering and limitation of chronic back pain.

Author's Comments:
Hodgkin lymphoma(HL) accounts for about 1/7 of all lymphomas. The most common presenting symptom is painless lymphadenopathy. Approximately 1/3 of patients have unexplained fever, night sweats, and weight loss. Dermatologic manifestations include generalized pruritus and new onset of eczema, which many experience at some point during disease course. Bone involvement is uncommon, occurring in up to 20% of cases and being radiographically evident in only 10-25% of those cases. Spine is the most common bony site. The majority of early bone lesions are lytic; however, blastic lesions are also common. Staging is I-IV. HL has an overall good prognosis, having an overall 5-year relative survival rate of 86%.
Common musculoskeletal complaints can sometimes represent a more serious etiology. This case is a good example of a very rare non-mechanical cause of chronic low back pain. Red flag symptoms should always be evaluated; however, symptoms can sometimes be insidious, as in our patient. A benign exam is particularly uncommon. One should always be more suspicious in a young healthy active patient with unrelenting chronic back pain, especially when there is no history of trauma, location is atypical, and night pain develops. New or worsening dermatologic manifestations should also trigger a clue for malignant neoplasms, most commonly in HL.

Editor's Comments:
While this may initially seem like a standard case of musculoskeletal back pain, it does highlight the importance of a good history and physical exam. The patient's report of night-time pain, coupled with failure to respond to conservative treatments, prompted further imaging which ultimately led to the diagnosis.

References:
Glass C. Role of the Primary Care Physician in Hodgkin Lymphoma. Am Fam Physician. 2008;78(5):615-622.

Asma J, et al. Hodgkin lymphoma (musculoskeletal manifestations). https://radiopaedia.org/articles/hodgkin-lymphoma-musculoskeletal-manifestations-1

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