The same adenopathy: Two diagnosis

Abstract

We report the case of an 83 year-old woman who was hospitalized with dyspnea, dry cough, diffuse abdominal pain associated with abdominal distension, asthenia, anorexia and weight loss over the last six months. Fever, night sweats, pruritus, urinary or gastro-intestinal complaints were not present. She had a history of hypertension, obesity (BMI32Kg/m2), heart failure and stroke without squeal. Her physical examination showed decreased bilateral breath sounds with coarse crackles; abdominal distension with dullness to percussion; no masses or organomegaly, small-volume ascites; hard-elastic, painless, immobile adenopathies, with about 1 cm at the neck (right jugular chain) and 3 cm at the right inguinal region. Abdominal ultrasonography revealed ascites and multiple mesenteric and retroperitoneal adenopathy. A laboratory evaluation demonstrated positive C-reactive protein (RCP) (13 mg/dl; N<6), increased ESR (83 mm; N<15), normocytic normochromic anemia (hemoglobin 11,2 g/dl ), high levels of serum Angiotensin Converting Enzyme (ACE) ( 191,6UI/L; N<52) and elevation of CA125 tumoral marker (4052,7 UI/ml; N<35). Blood cultures, urine culture, Mantoux skin test and Mycobacterium tuberculosis research were negative. Chest and abdomino-pelvic Computed Tomography scan showed mediastinal lymphadenopathy and bilateral pulmonary fibrosis; ascites with pelvic and retroperitoneal adenopathies; suspicious appearance of the endometrium and images suggestive of peritoneal carcinomatosis. Gynecological study revealed a nodular mass compatible with left adnexal tumor and we performed an excisional biopsy of the right inguinal lymph node. Surprisingly, we found the following histopathological result: many noncaseating epithelioid granulomas (sarcomatoid type) in half of the lymph node (Figure 1, left field) and neoplastic epithelial proliferation compatible with metastatic carcinoma in other half of the lymph node (Figure 1, right field) whose immunohistochemical study suggested that it was an ovarian carcinoma (Positive estrogen, MNF 116, CK7, CAM 5.2; Negative vimentin, CK20, high molecular weight CK-34βE12). She was targeted for palliative treatment and died