| We present a patient diagnosed as having tuberculous lymphadenitis after lymph node biopsy and referred for tuberculous therapy. On review, because of recent cat exposure, she was tested for cat scratch disease (CSD), but serological tests for bartonella henselae were negative. However, the diagnosis of CSD was confirmed, and tuberculosis excluded, by polymerase chain reaction techniques. This case serves as a reminder that CSD may mimic tuberculosis histologically and that sensitive molecular diagnostic tests are available. ( info) |
2/401. hiv combination therapy: immune restitution causing cryptococcal lymphadenitis dramatically improved by anti-inflammatory therapy. Two patients with AIDS developed microscopically verified focal cryptococcal lymphadenitis while treated with highly active anti-retroviral therapy for 8 and 15 months. Both were treated with fluconazole as a secondary prophylaxis for prior cryptococcal meningitis. cryptococcus neoformans did not grow. Amphotericin was ineffective. Anti-inflammatory drugs had a dramatic effect. ( info) |
3/401. The histopathology of cutaneous lesions of Kikuchi's disease (necrotizing lymphadenitis): a report of five cases. Kikuchi's disease (KD) is an idiopathic, self-limited necrotizing lymphadenitis that can clinically and histologically mimic high-grade lymphoma, including Hodgkin's disease, or can be mistaken for the lymphadenitis of systemic lupus erythematosus (SLE). Involvement of extranodal sites is unusual but well documented, especially in asia, where KD is more common than in north america or europe. The successful distinction of KD from malignant lymphoma and SLE is imperative for the appropriate treatment of affected patients. We describe five patients with cutaneous involvement by KD, all of whom presented with fever, lymphadenopathy, and an eruption on the skin of the upper body, which in one case was clinically suspected to be due to SLE and in another, polymorphous light eruption. The patients ranged in age from 10 months to 42 years (median, 33 years) and included three females and two males. All five patients had negative serologic studies for collagen vascular disease. Each patient had a lymph node biopsy showing the typical necrotizing lymphadenitis of KD. Skin biopsies from all five patients shared a specific constellation of histologic features: vacuolar interface change with necrotic keratinocytes, a dense lymphohistiocytic superficial and deep perivascular and interstitial infiltrate, varying amounts of papillary dermal edema, and abundant karyorrhectic debris with a conspicuous absence of neutrophils and a paucity of plasma cells, paralleling the nodal histology in KD. CD68 immunohistochemistry on paraffin-embedded sections showed many histiocytes and plasmacytoid monocytes in all cases, whereas CD3, CD4, and CD8 showed highly variable staining among the cases. There was only rare staining with TIA-1 and CD30. We believe that the papular eruption of KD has recognizable histopathologic features and that a CD68 stain that marks many cells that initially seem to be lymphocytes can be performed to confirm the diagnosis. ( info) |
4/401. listeria monocytogenes and recurrent mycobacterial infections in a child with complete interferon-gamma-receptor (IFNgammaR1) deficiency: mutational analysis and evaluation of therapeutic options. We describe the history of a girl with interferon-gamma-receptor (IFNgammaR1) deficiency and studies performed to identify the molecular and clinical characteristics of this recently discovered disorder. This is the first report of a child from Northern europe with IFNgammaR1 deficiency. The patient, now 7 years old, first presented with swelling and reddening at the Bacille Calmette-Guerin (BCG) vaccination site, swelling of lymph nodes, hepatomegaly, and an unusually severe varicella rash at the age of 4 months. At that time, she was diagnosed with BCG histiocytosis without typical granuloma formation and was treated with antituberculous agents. During the clinical course of her illness, several different types of atypical mycobacteria and (for the first time in an IFNgammaR1-deficient patient) listeria monocytogenes were detected. Flow cytometric analysis showed that the patient's monocytes could not bind a monoclonal antibody specific for the IFNgamma-receptor. Our analysis of mRNA derived from the alpha-chain (IFNgammaR1) gene of this receptor revealed deletions of 173 bp and 4 bp in cDNA sequences originating from individual alleles. The 173 bp deletion was located between nucleotide positions 200 and 372, exactly matching those of exon 3, and the 4 bp deletion was located between nucleotide positions 561 and 564 of the coding region of the cDNA. Analysis of genomic dna revealed the presence of a G to T transition at the 5'end of the splice consensus sequence of intron 3, which explains the absence of exon 3. The other allele carried the 4-base-pair deletion (ACTC) at nucleotide positions 15-18 of exon 5. Twelve months after an allogeneic bone marrow transplantation, the patient had clinically improved. ( info) |
5/401. Surgery for cervicofacial nontuberculous mycobacterial adenitis in children: an update. OBJECTIVE: To assess optimal surgical treatment with excision or curettage techniques in children with cervicofacial nontuberculous mycobacterial (NTM) adenitis. DESIGN: Retrospective case series. SETTING: Tertiary university-based pediatric referral center. patients: patients younger than 18 years diagnosed as having cervicofacial NTM adenitis by positive mycobacterial cultures or stains, or by histopathologic evaluation. INTERVENTIONS: Fine-needle aspiration biopsy for diagnosis, surgical excision and/or curettage of head and neck lesions for treatment. MAIN OUTCOME MEASURES: Number of procedures per patient, complications, resolution of mass. RESULTS: A total of 32 surgical procedures were performed in 25 children with cervicofacial NTM adenitis (mean, 1.3 procedures per patient; range, 1-3): 19 excisional and 13 curettage procedures. The 14 children who had excision as an initial procedure required no additional surgery. Of 11 children who had curettage as an initial procedure, 6 (55%) required additional procedures. Three of these children had additional surgery as planned staged procedures. Excisional surgery after initial curettage (5 patients) was simplified by initial debridement and secondary healing. No complications of curettage were noted. Transient marginal mandibular nerve weakness was seen in 4 patients who had excision. Fourteen of 16 fine-needle aspiration biopsy specimens were diagnostic for NTM adenitis. CONCLUSIONS: Cervicofacial NTM adenitis can be treated with excision or curettage. Excision remains the treatment of choice because of the high cure rate with a single procedure. We now consider curettage as a staged procedure for lesions in proximity to the facial nerve or with extensive skin necrosis, with initial curettage simplifying subsequent excision and wound closure. Preoperative counseling should include discussion of planned or unplanned revision surgery after curettage. Fine-needle aspiration biopsy allows early diagnosis of NTM adenitis. ( info) |
| Left recurrent laryngeal nerve palsy usually results from invasion or compression of the nerve caused by diseases localized within the aortopulmonary window. This study reports the case of a 76-yr-old male with vocal cord paralysis due to lymph node involvement by silicosis. This rare entity was identified by video-mediastinoscopy, which revealed a granulomatous and fibrosed recurrent lymph node encasing the nerve. The nerve was dissected and released from scar tissues. Progressive clinical improvement was observed followed by total and durable recovery of the voice after 15 weeks follow-up. ( info) |
7/401. Demonstration of parasites in toxoplasma lymphadenitis by fine-needle aspiration cytology: report of two cases. Two cases of toxoplasma lymphadenitis diagnosed by fine-needle aspiration (FNA) cytology, in which the microorganisms were identified in the cytologic preparations, are presented. The first case was that of an 8-yr-old boy with bilateral cervical lymphadenopathy of 2-mo duration, in which an FNA specimen of one of the lymph nodes in a Papanicolaou-stained smear disclosed a toxoplasma cyst, and in Wright-Giemsa preparation, dispersed tachyzoites and a pseudocyst. The second case was that of a 52-yr-old man with enlargement of a single lymph node in the neck, of 3-mo duration, FNA of which in Wright-Giemsa preparation disclosed numerous tachyzoites dispersed free in exudate, and also within cells, forming pseudocysts. In both cases, immunocytochemistry by the peroxidase method for toxoplasma gondii antigen was positive. The tachyzoites seen in Wright-Giemsa preparations, when subjected to fluorescence microscopy, emitted autofluorescence, facilitating their identification. While the presence of parasites in toxoplasma lymphadenitis is quite unusual, having been reported occasionally in histologic preparations and only rarely in cytologic FNA materials, our 2 cases suggest that in active disease, tachyzoites may not be so uncommon in FNA specimens. Besides the use of immunocytochemistry in the diagnosis of the disease, air-dried preparations stained by the Wright-Giemsa method are valuable for the demonstration of such parasites through careful search, along with the possible use of fluorescence microscopy. ( info) |
8/401. Disseminated infection due to rapidly growing mycobacteria in immunocompetent hosts presenting with chronic lymphadenopathy: a previously unrecognized clinical entity. Disseminated infection due to rapidly growing mycobacteria is uncommon and occurs mostly in immunocompromised patients. We report 16 cases of such infection with an unusual presentation seen at Srinagarind Hospital, a university hospital in northeastern thailand. The clinical features were different from those in previous reports. All of the patients presented with chronic bilateral cervical lymphadenopathy. Twelve had mycobacterial involvement of other organs (sinuses, 6 patients; lungs, 4; liver, 4; spleen, 3; skin, 3; bone and joint, 2; and tonsils, 2). An interesting occurrence in 11 patients was 14 episodes of reactive skin manifestations (Sweet's syndrome, 9; generalized pustulosis and erythema nodosum, 2 each; and pustular psoriasis, 1). No identifiable predisposing factors, including human immunodeficiency disease, were found in these patients. However, 8 patients had 11 episodes of prior infection or coinfection with other opportunistic pathogens (salmonellosis, 4; penicilliosis, 3; pulmonary tuberculosis, 2; and melioidosis and cryptococcosis, 1 each). These findings suggest that cell-mediated immunity is defective in these patients. ( info) |
9/401. A case of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) together with total atelectasis of a lung caused by lymphadenopathy and pleural effusion. Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) is a clinicopathologic entity established by Frizzera in 1974. Reported cases of AILD with pleuropulmonary involvement have been increasing recently. At Nogata Central Hospital, an 82-year-old male inpatient with brain infarctions and chronic bronchitis showed a rapid growth of systemic lymphadenopathy and various other symptoms. We diagnosed the case as AILD by histopathologic examination of a lymph node. Chest radiography and computed tomography demonstrated a loss of volume of the right lung caused by intrathoracic lymphadenopathy and a pleural effusion. Although cases of AILD with pleuropulmonary involvement have been increasing, no cases with almost total atelectasis of a lung have been reported as yet. AILD should be taken into account as a disease which may cause atelectasis of a lung. ( info) |
10/401. Sinus histiocytosis: some radiologic observations. Sinus histiocytosis with massive lymphadenopathy is an unusual disease characterized by prominent lymph node enlargement, especially in the cervical region. The clinical course is benign although prolonged, and no specific treatment is required. The etiology and pathogenesis are unknown. Four cases of sinus histiocytosis are reported, one in association with mediastinal lymph node enlargement and two in patients with orbital enlargement. One other patient had cervical masses. The radiologic features are reviewed to increase awareness of this entity as a cause of lymph node and orbital enlargement. ( info) |