BACKGROUND: Sarcoid-like reaction, characterized by noncaseating epithelioid granulomas, occurs in 13.8% of Hodgkin lymphoma cases. When the granulomatous component is prominent and neoplastic cells are scarce, the initial biopsy may lead to a misdiagnosis of sarcoidosis. Reliance on pathological findings alone, without integration of the clinical context, can result in considerable diagnostic delay.

CASE REPORT: A 63-year-old man with systemic lymphadenopathy underwent cervical lymph node biopsy, which showed epithelioid granulomas without identifiable neoplastic cells. Sarcoidosis was initially suspected based on the pathological findings. However, comprehensive evaluation revealed no typical manifestations of sarcoidosis, including bilateral hilar lymphadenopathy, uveitis, or elevated serum angiotensin-converting enzyme levels. The discordance between the pathological diagnosis and clinical findings led us to retain malignant lymphoma in the differential diagnosis. During follow-up, the patient developed B symptoms with substantially elevated soluble interleukin-2 receptor levels. Repeat biopsy of the left supraclavicular lymph node, performed 7 months after the initial presentation, revealed Reed-Sternberg-like multinucleated cells surrounded by a sarcoid-like reaction, confirming classical Hodgkin lymphoma.

CONCLUSIONS: This case illustrates that pathological findings alone may be insufficient for a definitive diagnosis of granulomatous lymphadenopathy. Malignant lymphoma should remain in the differential diagnosis, even when the initial biopsy suggests sarcoidosis. When clinical features are inconsistent with the pathological diagnosis, clinicians should reconsider the differential diagnosis, and repeat biopsy may be warranted. Integration of clinical findings, imaging, and histopathology is important to avoid diagnostic delay.

Keywords: sarcoidosis, Hodgkin Disease, Granuloma, lymphadenopathy, Biopsy, Diagnosis, Differential