EBV-positive Hodgkin lymphoma with an immunosuppressive microenvironment during guselkumab (interleukin-23 inhibitor) therapy for chronic plaque psoriasis.
Bhaumik Shah, Janusz Franco-Barraza, Kathy Q Cai et al.
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Case in brief
A man in his early 40s with chronic plaque psoriasis and psoriatic arthritis developed night sweats, syncope, and bulky right cervical lymphadenopathy seven months after starting guselkumab. Excisional biopsy showed mixed-cellularity, EBV-positive classic Hodgkin lymphoma with latency IIa. The lymph-node microenvironment included CTLA4-positive immunosuppressive T cells, M2 macrophages, modest Th2 skewing, and Th17 cells. Guselkumab was stopped; he achieved a complete metabolic response after ABVD and involved-site radiotherapy and remains in remission on apremilast.
What made this case unusual
The tumor microenvironment was Th2-skewed and myeloid-enriched, unlike the typical Th1-dominant profile described for EBV-positive classic Hodgkin lymphoma. The short interval after guselkumab initiation raises the possibility of immune-milieu alteration, but does not establish causation.
Diagnostic / clinical pearl
In a patient receiving an IL-23 inhibitor who develops systemic symptoms and bulky lymphadenopathy, tissue biopsy with EBV studies can establish classic Hodgkin lymphoma and characterize its subtype and microenvironment.
Why it matters
The case supports continued pharmacovigilance for rare lymphomas during IL-23 inhibitor therapy; larger studies are needed to clarify whether there is a class effect.