Triple Trouble: Hepatitis B-related Cirrhosis With Hodgkin Lymphoma-Associated Paraneoplastic Pseudoachalasia

Pseudoachalasia is a rare motility disorder that occurs secondary to various disorders, including malignancies. Clinical, endoscopic, and manometric features of pseudoachalasia mimic primary achalasia. Paraneoplastic pseudoachalasia is an uncommon form of pseudoachalasia associated with malignancies, such as small cell lung carcinoma, neuroendocrine tumors, acute leukemia, and lymphomas. Symptoms of paraneoplastic pseudoachalasia can occur early, together, or delayed compared to those of primary malignancy. The pathophysiology of paraneoplastic achalasia involves autoantibody-induced destruction of the myenteric plexus of the esophagus. We report a case of an 18-year-old male who presented with dysphagia, anorexia, weight loss, and ascites, which were suggestive of achalasia. Further investigations revealed hepatitis B-related cirrhosis with portal hypertension and enlarged para-aortic and aorto-caval lymph nodes. Endoscopic ultrasound-guided fine-needle biopsy of the lymph nodes confirmed the diagnosis of Hodgkin's lymphoma. High-resolution manometry revealed type II achalasia cardia, which is likely a paraneoplastic manifestation of Hodgkin's lymphoma. The patient underwent endoscopic pneumatic dilation for symptom relief and was referred for further management of Hodgkin's lymphoma. This case highlights the importance of considering paraneoplastic pseudoachalasia in patients presenting with achalasia-like symptoms, especially in the presence of significant weight loss and anorexia.