Right Groin Pain In A Collegiate Offensive Lineman

Abstract

HISTORY: The patient was a 21-year-old football player who had been having atraumatic right groin pain for one month. He reported feeling a lump in the area of the pain. The pain was worse with activity and relieved by rest. He had also been experiencing subjective fevers, night sweats, nausea, and fatigue. He endorsed an intermittent rash during the course of the first month of symptoms that became very pronounced during a short episode of viral gastroenteritis. Trials of antibiotics did not improve symptoms. PHYSICAL EXAMINATION: He was a well appearing male that was afebrile. His abdominal and genitourinary exam revealed a soft and nontender abdomen with normal bowel sounds. There was no evidence of a right inguinal hernia. There was no testicular mass or epididymal tenderness. No discrete nodules were palpable in the right groin but there was fullness in the area compared to the opposite side. On examination of the right hip he was nontender to palpation over the anterior hip and moderately tender over the proximal hip adductors. There was no tenderness to palpation over the greater trochanter. He had full range of motion with hip flexion, extension, abduction, and adduction without pain. He reported some pain with resisted adduction. FADIR test was negative. DIFFERENTIAL DIAGNOSIS: Adductor tendonitis, Inguinal hernia, Lymphadenopathy, Lymphoma, Lymphogranuloma venereum, Kawasaki disease, and Kikuchi-Fujimoto disease. TEST AND RESULTS: CMP, CBC, and UA were without significant findings. HIV, hepatitis B, hepatitis C, and Epstein Barr virus were negative. ESR, CRP, rheumatoid factor, and ANA were within normal limits. Lyme Disease test was negative. A diagnostic ultrasound showed a lobulated hypoechoic nodule with a fatty hilum in the right inguinal region with a volume of 6.9 mL consistent with a reactive lymph node. Pathology of the lymph node showed histiocytic necrotizing lymphadenitis consistent with Kikuchi-Fujimoto without evidence of malignant lymphoma or metastatic carcinoma. FINAL WORKING DIAGNOSIS: Kikuchi-Fujimoto Disease TREATMENT AND OUTCOMES: He was started on a prednisone taper to which he had dramatic symptom improvement but with a rebound in symptoms after completing the course. He was then started on hydroxychloroquine and reported adequate symptom improvement for football participation.