A 32-year-old male from Delhi presents with painless cervical lymphadenopathy and constitutional symptoms (fever, night sweats, weight loss). Lymph node biopsy shows classical Hodgkin lymphoma. All of the following are accurate regarding the epidemiology and etiology of Hodgkin lymphoma in India EXCEPT:

Explanation

## Epidemiology and Etiology of Hodgkin Lymphoma ### Age Distribution and Global Patterns **Key Point:** Hodgkin lymphoma shows a bimodal age distribution in developed countries with peaks in the 20s–30s (young adults) and 55+ years (older adults). In developing countries, including India, the distribution may be skewed toward younger ages. ### Histological Subtypes in India | Subtype | Frequency (Developed) | Frequency (India/Developing) | Key Features | |---------|----------------------|------------------------------|---------------| | **Nodular Sclerosis** | 60–70% | 40–50% | Fibrosis bands, lacunar cells | | **Mixed Cellularity** | 15–25% | 30–40% | Numerous RS cells, diffuse infiltrate | | **Lymphocyte-Rich** | 5% | <5% | Abundant small lymphocytes | | **Lymphocyte-Depleted** | <5% | <5% | Numerous RS cells, few lymphocytes | **High-Yield:** In India and other developing countries, **mixed cellularity** is often more common than nodular sclerosis, contrary to the pattern in Western countries. This is an important epidemiological distinction. ### EBV Association **Key Point:** EBV is associated with approximately 40% of Hodgkin lymphoma cases globally. The association is stronger in: - Developing countries (up to 80–90% in some regions) - Mixed cellularity and lymphocyte-depleted subtypes - Older patients - Immunocompromised individuals ### Immunocompromise and Risk **Clinical Pearl:** Hodgkin lymphoma incidence is markedly elevated in HIV-positive individuals (100–300 times higher than general population), particularly when CD4+ count is <50 cells/μL. This is a well-established risk factor. ### Why Mixed Cellularity is More Common in India The statement that "nodular sclerosis is the most common variant in India" is **incorrect**. While nodular sclerosis remains the most common subtype globally, in India and other developing countries with higher EBV prevalence, **mixed cellularity** is often equally common or more prevalent than nodular sclerosis. This reflects the higher burden of EBV-associated disease in these populations. [cite:Robbins 10e Ch 13]