Hodgkin Lymphoma: An Unusual Presentation With Hemophagocytic Lymphohistiocytosis

Hodgkin lymphoma (HL) can present with non-specific systemic symptoms, often mimicking infection, autoimmune disease, or post-surgical complications. When compounded by recent major surgery and ongoing inflammatory features, diagnosis can be significantly delayed. This case highlights the diagnostic complexity of HL in a postoperative setting, complicated by recurrent sepsis-like presentations, persistently raised inflammatory markers, and overlapping differentials, including graft infection and hemophagocytic lymphohistiocytosis (HLH). A 71-year-old male underwent elective abdominal aortic aneurysm (AAA) repair, complicated by significant intraoperative blood loss. He initially recovered but began presenting with recurrent fevers, abdominal pain, vomiting, and deranged liver function tests (LFTs). He underwent comprehensive imaging, which revealed peri-graft fluid collection on CT, fluorodeoxyglucose (FDG)-avid lymphadenopathy on PET/CT, and a mobile aortic valve structure on an echocardiogram, raising concerns for a graft infection, disseminated infection of unknown origin, and infective endocarditis, respectively. Despite multiple courses of intravenous antibiotics, he continued to have persistent fever spikes, and bicytopenia coupled with hyperferritinemia prompted consideration of HLH or malignancy. Further imaging, including a liver MRI and PET imaging, revealed multiple hyperintense hepatic foci and widespread nodal uptake. With clinical deterioration, the patient was empirically treated with anakinra and steroids for HLH with an unclear underlying driver, resulting in temporary improvement. Bone marrow biopsy ultimately confirmed a diagnosis of HL. This case highlights the importance of maintaining a broad differential when managing persistent systemic inflammation following surgery. HL should be considered when infection and autoimmune causes are excluded, especially in the presence of FDG-avid lymphadenopathy, cytopenias, and hyperferritinemia. Early hematology involvement and tissue diagnosis are key to avoiding delays in treatment.