Background and aims Fever is one of the most common complaints presenting in the emergency department (ED). When associated with bone pain, osteo-articular infections are the most likely diagnosis, however other causes, including neoplasms should be considered.

Methods, results 11 year old girl, previously healthy, presented in the ED with a low grade persistent fever associated with a left shoulder pain lasting for 3 weeks. Anorexia and weight lost (3%) were also noted. Consumption of nonpasteurized dairys, contact with animals or travelling were denied. On admission she presented: pallor, a painful interscapular mass that implied an antalgic position and multiple anterior cervical adenopathies. Laboratory findings revealed leukocytosis with neutrophilia, CRP 98 mg/L and ESR 86 mm/h. Considering spondylodiscitis empirical antibiotic therapy was initiated. Further investigation regarding infectious diseases was performed including: serologies for EBV, CMV, HIV 1 and 2, Mycoplasma pneumoniae, Toxoplasma gondii, Coxiella burnetii, Bartonella, Brucella, Mantoux and IGRA tests, and blood culture (30 day protocol) and were all negative. Uric acid, LDH and blood smear were normal. On day 5 of admittance MRI of the spinal column revealed a left 12 cm mass between D1 and D7 involving the spinalis thoracis with vertebral and foraminal invasion. Aspirative citology and biopsy of the mass revealed classic Hodgkin lymphoma (HL). Patient underwent CT and PET scan which defined stage IV B HL.

Conclusion Muscle masses are a rare presentation of HL. Although musculoskeletal pain is an atypical presentation when associated with systemic complaints and lymphadenopathy HL should be considered.