Axillary Lymph Node Enlargement Research Articles

Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome with Toxic Epidermal Necrolysis: Overlap in an HIV Seropositive Male with Diffuse Large “B” Cell Lymphoma – A Rare Case Report

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug-induced hypersensitivity reaction with varied presentations. We report a rare case of DRESS syndrome with toxic epidermal necrolysis (TEN) overlap associated with non-Hodgkin lymphoma (NHL). A 52-year-old male with retroviral disease presented with fever and diffuse skin peeling with mucosal erosions. The patient was on antitubercular therapy (ATT) for 1 month for suspected tubercular cervical lymphadenitis. He had facial edema, extensive skin tenderness, and denudation with a positive Nikolsky’s sign, icterus, hepatosplenomegaly and multiple enlarged immobile nontender cervical, and axillary and inguinal lymph nodes. Investigations showed leukocytosis with hepatic and renal dysfunction. Skin histopathology was consistent with TEN. Based on Registry of Severe Cutaneous Adverse Reaction criteria, a diagnosis of ATT-induced DRESS with TEN overlap was made. Cervical lymph node biopsy and immunohistochemistry confirmed diffuse large B-cell NHL. ATT was withheld and the patient was treated with systemic steroids and assessed for initiation of chemotherapy. The profound immunological dysregulation in individuals with retroviral disease leads to varied clinical presentations, increasing the chances of diagnostic errors, and culminating in challenging scenarios. Therefore, seemingly innocuous symptoms and signs warrant thorough evaluation. Sound clinical acumen and prompt investigations for unusual causes such as malignancies can improve outcomes by aiding accurate diagnosis as well as avert untoward complications such as DRESS syndrome/TE.

Non-Hodgkin’s Lymphoma Presenting Section as a Soft Tissue Mass on Right Thigh

Non-Hodgkin’s Lymphomas (NHL) are a heterogeneous group of lymphoproliferative malignancies with a greater preference for disseminating to extranodal locations. Prevalence of extranodal involvement in NHL has increased in the past decade, and the sites involved are the stomach, spleen, waldeyer’s ring, Central Nervous System (CNS), lungs and skin. This is a rare case of NHL in a 48-year-old female who presented with solitary exophytic mass with ulceration over the right thigh and erythematous plaque over postaxillary region and enlarged right inguinal and left axillary lymph nodes. Magnetic Resonance Imaging (MRI) of the right thigh showed lobulated mass involving skin and subcutaneous soft tissues without any intramuscular extension suggestive of neoplastic mass. Fine needle aspiration cytology of the inguinal node and biopsy of the right thigh lesion showed features suggestive of NHL. She was treated with three cycles of Cyclophosphamide, Hydroxydaunorubicin, Oncovin and Prednisone (CHOP) regimen, but the patient succumbed to death after six months of chemotherapy

Metastatic non-muscle invasive transitional cell carcinoma of urinary bladder: a case report

BackgroundAxillary lymphadenopathy is a common clinical presentation of variety of benign and malignant diseases. However, majority of patients with unilateral axillary lymph node enlargement have an underlying malignancy in which association with breast carcinoma being the commonest one. In most of these patients there will be a discernible primary tumor, either clinically or radiologically. However, in axillary lymphadenopathy with negative mammogram is not very common, and in this case other malignant causes should also be considered in addition to occult breast cancer and these can be metastases from other primary tumors for, e.g., lung, genitourinary tract, gastrointestinal, ovarian, thyroid carcinomas and malignant melanoma.Axillary node is an uncommon site of metastases from Transitional cell carcinoma (TCC) of urinary bladder even from its muscle invasive form, and distant metastasis from low grade superficial tumors without muscle invasion or regional metastasis is a very rare occurrence. Here we present a case of axillary nodal metastases from non-muscle invasive (superficial) bladder cancer without history of local recurrence and regional metastases.Case presentationWe present a case of female patient who complaint of hard swelling in right axilla and right breast enlargement. Patient had past history of non-muscle invasive transitional cell carcinoma of urinary bladder (pTa, grade II A) which had been treated accordingly. No recurrence of bladder growth had been observed on serial check cystoscopies. On clinical examination of breast and axilla, right breast appears enlarged and there were palpable hard fixed axillary lymph nodes. Ultrasound showed enlarged malignant looking lymph nodes. Occult breast carcinoma with metastatic axillary lymph nodes was our initial impression; however, subsequent biopsy of axillary lymph nodes showed Transitional cell carcinoma.ConclusionsThis patient’s case emphasizes the importance of having sound knowledge of natural behavior of primary tumor and common and uncommon sites of distant metastases. The causes of unilateral axillary lymphadenopathy include both benign and malignant disease.

Occult breast cancer presenting as metastatic carcinoma in a right axillary lymph node of a post-menopausal female: A case report and review of literature

Introduction: Occult breast cancer (OBC) is a clinically recognizable metastatic carcinoma from an undetectable primary breast tumor. It is rare and accounts for 0.3–1% of all breast cancers, often presenting with lymph node, bone, or skin metastases. It poses a diagnostic challenge for general surgeons, radiologists, and pathologists. Case Report: We present the case of occult breast cancer in a 62-year-old, post-menopausal, female, Nigerian, presenting with a solitary, painless, right axillary lymph node enlargement without a clinical or radiological evidence of a breast mass; and also review the literature. The diagnosis of metastatic breast carcinoma was made and confirmed on histology and immunohistochemistry analysis of the axillary lymph node. Histological examination of the subsequent right breast mastectomy specimen revealed the presence of infiltrating ductal carcinoma even though no definite mass lesion was seen on gross examination. Conclusion: Occult breast cancer can be a diagnostic challenge and should be excluded in any patient presenting with solitary axillary lymphadenopathy. Immunohistochemistry staining patterns can be a mainstay in resolving the differential diagnoses.

ODP093 Hunt for Hypercalcemia

Abstract Hypercalcemia is a relatively common clinical problem. Among all causes of hypercalcemia, primary hyperparathyroidism and malignancy are the most common. This case highlights the importance of collaboration between subspecialists to identify the etiology of a patient's hypercalcemia. A 71-year-old male with history of tobacco use and untreated hepatitis C, presented to the emergency department with several weeks of progressively painful, non-traumatic right upper extremity (RUE) swelling. Chest CT showed a 1.4 cm right axillary lymph node and the patient was referred to general surgery for a biopsy which was deferred due to size. Due to worsening lymphedema, the patient underwent a venogram with plans for a lymphedema pump, however in the interim he presented with worsening RUE edema. Labs were notable for Ca 12.7 mg/dL(8.6-10.3) though the patient reported taking chlorthalidone and calcium-based antacids. The patient was admitted with lymphedema progression and new-onset hypercalcemia. Labs were significant for suppressed PTH 6.8 pg/ml(10-66), undetectable PTHrP, Vit D 9.9 ng/mL(32-100), 1,25-Vit D 110 pg/mL(19.9-79.3), and SPEP/UPEP without an M-spike. Additional labs included PSA 17.96 ng/mL(0-3.9) and LDH 3471 units/L(94-260). Chest CT demonstrated a few sub-centimeter calcified pulmonary nodules with the appearance of chronic granulomas, but no evidence of hilar or mediastinal lymphadenopathy, significantly reducing the likelihood of sarcoidosis. RUE CT showed cortical destruction of the humeral head and proximal shaft, along with infiltrative enlargement of the muscles. There were also a few enlarged axillary lymph nodes, the largest measuring 2 cm. The patient was hydrated with initial improvement of his labs however calcium subsequently increased to 13.5 mg/dL. Due to concern for 1,25-Vit D mediated hypercalcemia and the source still unknown, the patient was started on prednisone 20 mg with normalization of the calcium level. An excisional lymph node biopsy followed by flow cytometry confirmed the diagnosis of diffuse large B cell lymphoma(DLBCL). The patient was treated with chemotherapy and had since been in remission. Of note the patient was also found to have localized prostate cancer treated with external beam radiation . Hypercalcemia is estimated to occur in approximately 30% of patients with malignancy and is associated with a poorer prognosis. Mechanisms include humoral hypercalcemia (PTHrP), osteolytic cytokine production, extensive bone metastasis in the absence of excess osteolytic factors, and production of 1,25-Vit D. Our patient had several risk factors for hypercalcemia including thiazide and antacid use, which may cause milk-alklai syndrome; an elevated PSA, which was eventually confirmed to be prostate cancer; and an elevated 1,25-Vit D of unknown etiology. Due to the risks associated with hypercalcemia and after extensive conversations amongst the subspecialists, the decision was made to start empiric treatment with prednisone. Eventually the patient underwent CT guided biopsy confirming the diagnosis of DLBCL, but it was a "hunt". Presentation: No date and time listed

CD8+ Mycosis Fungoides in Peripheral Blood; A Rare Finding

Cutaneous T cell lymphomas are mature lymphomas of T lymphocyte presenting with skin lesions and/or systemic manifestations. Majority of these cases show CD4+ phenotype and are classified as Mycosis Fungoides (MF)/Sezary syndrome (SS) spectrum.
 Here we present a case of 74-year-old male patient, having no known comorbid, presented in Dr. Ziauddin Hospital, Karachi OPD with complains of generalized skin lesions, itching for 2 years, generalized weakness for 4 months and no lymphadenopathy or visceromegaly. CBC showed absolute lymphocytosis and absolute eosinophilia. Some lymphocytes exhibited cerebriform nuclei. CT scan neck, chest and abdomen showed bilateral enlarged superficial inguinal lymph nodes and multiple enlarged bilateral axillary lymph nodes. Skin biopsy was inconclusive. Immunophenotyping of peripheral blood was then performed which showed an aberrant T cell population showing positivity for CD3, CD8, CD2, CD25 and negative for CD4, CD45, CD5, CD30, CD56 with variable expression of CD7. Case was finalized as CD8+ Mycosis Fungoides with peripheral blood involvement.
 These findings are very rare and highlight the importance of integrated approach to clinical course, morphological findings and other ancillary tests to be used in correlation with each other. These findings also highlight the diversity present in T cell malignancies in terms of immunophenotype.

P486 Disseminated Cryptococcosis diagnosed on fine needle aspiration cytology

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PMObjectives (Case)A 48-year-old male with no prior comorbidities presented to our infectious disease clinic with intermittent low-grade fever and gradual progressive swelling in his left axilla for 3 months. On further probing, the patient also gives a history of weight loss of around 7 kg. The patient belonged to a northern state of the Indian subcontinent and owned a grocery shop, where he worked. There was no recent or remote travel history, no history of exposure to animals or birds, no high-risk behavior, and no past or known contact history of tuberculosis. Still, in an endemic country like India and in this given clinical scenario, we kept tubercular lymphadenitis as the first differential and investigated the case further.Methods (Investigation)A contrast-enhanced computed tomography (CECT) of the chest and abdomen was done, showing multiple enlarged mediastinal and axillary lymph nodes with bilateral adrenal mass (Fig. 1). To further evaluate the etiology, a fine needle aspiration of the left axillary swelling was done. A hematoxylin and eosin (H and E) stain of the same showed the presence of numerous organisms of varying sizes present both intracellularly and extracellularly along with chronic inflammatory cells (Fig. 2a). Based on this picture, differentials of Histoplasma, Cryptococcus, or Toxoplasma were kept. But considering the empty spaces (halos) which probably represent the capsule and variability in the size, a strong possibility of Cryptococcus was kept. Serum cryptococcal antigen (latex agglutination) was negative but eventually, the fungal culture of the aspirated sample grew cream-colored, shiny dome-shaped, mucoid colonies on Sabouraud Dextrose Agar suggestive of Cryptococcus (Fig. 2b). The same was confirmed on Bird Seed Agar and Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry (MS). Gene Xpert of the aspirated sample was negative and serum cortisol with serum adrenocorticotropic hormone (ACTH) were under normal limits.Results (Diagnosis)A diagnosis of disseminated cryptococcosis was made based on the involvement of more than two non-contiguous sites (mediastinal with axillary lymph nodes and adrenal gland). The patient was initially started on liposomal Amphotericin B (5 mg/kg intravenous daily) with which he improved clinically. Same was continued for 2 weeks and later he was shifted to fluconazole 400 mg daily. As of now, the patient is on his 3rd month of fluconazole and doing well on follow-up.ConclusionCryptococcus (Cryptococcus neoformans and Cryptococcus gattii) is an encapsulated yeast causing invasive fungal infection, with vast majority occurring in immunocompromised host1. It has a global distribution, predominantly involving the central nervous system (CNS) and lung. Management of non-CNS and non-pulmonary cryptococcosis is tricky as looking for dissemination is key (as the initial choice of agent varies)2. Adrenal involvement in Cryptococcosis is uncommon (as seen in our case). Examination of FNAC samples for Cryptococcus is also challenging as other microbes can also closely mimic the same. Finally, in a tuberculosis endemic country like India, clinical symptoms of Cryptococcal lymphadenitis can closely resemble tubercular lymphadenitis, so empirical therapy may be risky.Figure 1 Axial CT Chest images showing multiple enlarged mediastinal lymph nodes (red arrow).Figure 2a Fine needle aspiration cytology (FNAC) from the left axillary swelling stained with hematoxylin and eosin showing numerous organisms of varying size present both intracellularly (black arrow) and extracellularly with surrounding halos in a background chronic inflammatory cells.Figure 2b Fine needle aspirate sample incubated at 37 0C on Sabouraud Dextrose Agar with gentamicin showing cream-colored, dome-shaped, shiny, mucoid colonies with smooth edge (characteristic of Cryptococcus).Sources:Iyer KR, Revie NM, Fu C, Robbins N, Cowen LE. Treatment strategies for cryptococcal infection: challenges, advances and future outlook. Nat Rev Microbiol. 2021 Jul;19(7):454–66.Clinical Practice Guidelines for the Management of Cryptococcal Disease: 2010 Update by the Infectious Diseases Society of America | Clinical Infectious Diseases | Oxford Academic [Internet]. [cited 2022 Jul 28]. Available from: https://academic.oup.com/cid/article/50/3/291/392360

Young patients with unilateral breast cancer arising in fibroadenoma

The incidence of breast cancer with fibroadenoma (FAM) in young patients is a rarely reported case, <1% of all cases of women suffering from breast cancer. This case report aims to highlight the importance of considering the presence of FAM and breast cancer at the same time at a young age to be treated comprehensively. A 31-year-old woman with complaints a lump in the breast and pain. Mother has a history of breast lumps. There were no menstrual disturbances and the use of hormonal contraception. The results of breast ultrasound revealed a solid mass with a diameter of 4 cm in the central quadrant of the breast with a hypoechoic mass with malignant features in it according to the Breast Imaging Reporting and Data System (BIRADS) C-4 and enlarged right axillary lymph nodes. Results Fine Needle Aspiration Biopsy (FNAB) unspecified, finally, a wide excision was performed and it was found that there was a solid mass and a smooth mass with a clear capsule. Histopathological report shows invasive carcinoma in right breast fibroadenoma. Young patients with lumps in the breast are not only suspected of being FAM but can be considered an image towards invasive carcinoma.

Clinical analysis of 7 children infected with Talaromyces marneffei

Objective: To investigate the clinical manifestations, treatments, and prognosis of pediatric patients with Talaromyces marneffei infection. Methods: In this retrospective study, 7 children diagnosed with Talaromyces marneffei infection in Shenzhen Children's Hospital from July 2017 to October 2021 were recruited. The clinical features, radiology, pathogen detection, immunological evaluation, treatments, and prognosis were analyzed. Results: In 7 cases, 5 were male, 2 were females. The age was from 0.75 to 8.75 years. The main clinical manifestations were fever in 7 cases, cough in 6 cases, malnutrition in 4 cases, papules in 2 cases and medical history of recurrent infection in 3 cases. Physical examination showed that all 7 patients had hepatosplenomegaly, 4 had superficial lymphadenopathy. Laboratory examination showed that 6 cases had decreased hemoglobin and 3 cases had decreased platelet. Chest CT showed that 4 cases had patchy shadows, pleural effusion, mediastinal or axillary lymph node enlargement, 3 had nodular shadows and 2 had cavities. The positive ratio of Talaromyces marneffei culture was 2/2 with tissue samples, 4/5 with bone marrow. The positive ratio was 3/4 by metagenomic next generation sequencing. The fungus was detected in 3 cases by smear microscopy of bone marrow and (or) peripheral blood. All patients were negative for human immunodeficiency virus by the immune function assay. However, 5 cases were confirmed as primary immunodeficiency disease, including 2 cases with high IgM syndrome, 2 with STAT1 gene variation, and the last with severe combined immunodeficiency (IL2RG gene variation). Exclude 1 case which gave up treatment due to acute intracranial infection, and the other patients received effective treatments along with amphotericin B, voriconazole, and itraconazole alone or in combination. Two cases relapsed after medication withdrawal, but 1 case got complete rehabilitation after hematopoietic stem cell transplantation. Conclusions: The clinical manifestations involve multisystem, the common charateristics are fever and cough. The chest CT imaging manifestations are diverse, it should be considered in differentiating tuberculosis. The amphotericin B, voriconazole and itraconazole are effective, but it will easily relapse when withdrawing those antifungal agents.

BURKITT'S LYMPHOMA: MULTIPROFESSIONAL DIAGNOSTIC VIEW OF A DIFFICULT CASE

Burkitt's lymphoma (BL) is an aggressive form of non-Hodgkin's B-cell lymphoma that presents 3 forms: endemic, sporadic, and immunodeficiency-associated types. The objective is to report a case of BL diagnosed in the mandibular gingiva based on the initial manifestation of right axillary lymph node enlargement (>15 cm). Upon examination, an exophytic lesion was noted in the mandible, posterior region, bilateral, invading masticatory space. A head and neck computed tomography scan revealed a homogeneous solid expansive lesion in the right buccinator space, extending to retromaxillary fat. The anatomopathologic report was compatible with BL. The patient was treated with R-dose adjusted rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin and is being followed up with a reduction in the mass of lymph nodes and oral lesions. We concluded that the multiprofessional approach in conducting diagnosis is important for the best treatment. Also, it showed that the diagnosis of hematological neoplasm must include several professionals, making the treatment more individualized for the patient.

Malar rash with pancytopenia

Malar rash with pancytopenia

Cytomorphological spectrum of various breast lumps using FNAC as diagnostic modality

Background: Breast carcinoma is the most common malignant tumour and the leading cause of death from cancer in women. FNAC of breast lumps is an important mode of investigation and forms a part of triple test. FNAC is cost effective and can prevent unnecessary surgery. This study intended to look the frequencies of different lesions in FNAC of palpable breast lump. Methods: It is a hospital based prospective study conducted from November 2016 to October 2017 conducted in Department of Pathology, GMC Jammu. FNAC was done in a total of 289 patients who presented with palpable breast lump along with suspected enlarged axillary lymph node, if any. We assessed the age of the patient, lesion size, site, type of lesion and axillary lymph node metastasis in case of malignancies. Results: Out of 289 patients studied, 250 (86.5%) were females and 39 (13.4%) were males. Age ranges from 7-88 years with a mean age of 36 years. Most of the patients were in 21-30 years age group (30.6%). 241 cases (96.4%) presented with breast lump while the swelling was diffuse in 9 cases. Maximum number of cases in females were seen in the age group of 21-30 years i.e. 75 cases (30%). Upper outer quadrant was the most common quadrant involved in females with 70 cases (28%). On FNAC, there were 36 cases (12.4%) of Inflammatory lesions, 198 (68.5%) of benign cases and 29 cases (10.06%) of carcinoma breast. Among the benign lesions maximum number of cases i.e. 58 cases (20.06%) were reported as Fibroadenoma. On cytological categorisation of breast diseases on FNAC, maximum number of cases i.e. 221 (76.4%) were categorised as C2 (Benign) followed by 29 cases (10.06%) categorised as C5 (Malignant).

Unusual Recurrence of Malignant Melanoma After 14 Years, diagnosed by 18F-FDG PET-CT Imaging: A Case Report

According to the World Health Organization, the number of malignant melanoma cases increases faster worldwide. Early diagnosed and adequately managed malignant melanoma shows a good prognosis. Rare cases of late metastasis of melanoma after long disease free survival, and their growing incidences are reported. This reported case is about a metastatic malignant melanoma who was apparently disease free for 14 years but showed late recurrence and earned clinical interest. A 60-year-old male patient was referred to PET-CT division of National Institute of Nuclear Medicine & Allied Sciences (NINMAS) for the evaluation of a biopsy proven malignant melanoma in right inguinal region. The patient presented with a newly developed asymptomatic nodule on his right thigh. Relevant past medical history included a completely excised lesion in his left axilla for malignant melanoma. Fine-needle aspiration and cytological analysis report of new lesion showed subcutaneous localization of malignant melanoma. 18F-FDG PET-CT imaging showed hypermetabolic soft tissue density mass in right inguinal region; Histopathology report (HPR) proved malignant lesion. Multiple hypermetabolic lesions were seen intra abdominally involving spleen and pancreas with corresponding hypodense lesions on CT scan. Multiple hypermetabolic enlarged intraabdominal, right axillary and right inguinal lymph nodes are also evident. After 14 years of disease free survival the reported case developed malignant melanoma with distal metastases. Although late metastasis is uncommon however physicians should be aware of any newly developed suspicious lesions and PET-CT can play an important role in workup for detection of metastases from melanoma. Bangladesh J. Nuclear Med. 25(1): 45-47, 2022

Temporal heterogeneity of HER2 expression in metastatic gastric cancer: a case report

Gastric cancer is a disease with high heterogeneity, and this heterogeneity may result in an uneven distribution of subclones with varied genetic properties at disease locations (spatial heterogeneity) or temporal changes in subclonal composition (temporal heterogeneity). We present the case of a 69-year-old woman with metastatic gastric cancer who presented for axillary lymph node enlargement and underwent axillary lymphadenectomy. Pathological evidence showed human epidermal growth factor receptor 2 (HER2)(3+). Abdominal computed tomography revealed a mass in the gastric body, gastroscopic biopsy showed HER2(3+). After tumor shrinkage by preoperative translational chemotherapy (oxaliplatin, calcium folate, fluorouracil) and targeted therapy (trastuzumab), she had laparoscopic-assisted total gastrectomy. However, HER2 immunohistochemistry was found to be diffusely negative in the surgically removed tissue, and there was no evidence of HER2 amplification in the whole exon sequencing either. After 10 months of trastuzumab treatment, her disease progressed. Although trastuzumab treatment was initially beneficial, the residual HER2-negative subclones may cause tumor recurrence and metastasis due to temporal heterogeneity, as shown in this case.

The Role of Strain Elastography in Evaluating Borderline Axillary Lymph nodes

Background: Axillary lymph node (ALN) enlargement with diffuse cortical thickening and conserved echogenic hilum may represent a diagnostic and therapeutic challenge. Sonographic strain elastography may help the characterization of borderline ALN. Aim: To evaluate the strain elastography of borderline ALN and to calculate a cutoff value of strain ratio (SR) that can identify suspicious ALN with the highest sensitivity and specificity to reduce unnecessary invasive procedures. Subjects and Methods: A prospective study included 45 patients who attended the Breast clinic in Oncology Teaching Hospital with borderline axillary lymphadenopathy (intact hilum and diffusely thickened cortex more than 3mm) who had normal ipsilateral breast, suspicious ipsilateral breast lesion, or who had ipsilateral mastectomy. B-mode sonography and elastography were performed for all participants. Four-point elasticity score (ES), and SR were obtained for the targeted lymph node followed by ultrasound-guided fine need aspirate (FNA) biopsy.. Results: Malignant ALN constituted 20% of the cohort. B mode measurements were not able to differentiate between cytologically confirmed benign and malignant ALN in terms of axis ratio (mean ± standard deviation, 0.46 ± 0.08 vs 0.50 ± 0.12) and cortical thickness (4.88 ± 1.93 vs 6.27 ± 2.46). The mean SR of all samples was 2.66 ± 2.25. Metastatic ALN depicted significantly higher SR (P<0.0001), with 88.9% exhibiting ES score 3 and 4. None of the metastatic ALN had ES score 1. ROC curve was used to investigate the utility of SR as a diagnostic tool. The area under the curve (AUC) was 0.906 with a 95% CI of 0.814-0.997, P<0.001. SR cutoff of 2.1 was chosen with 100% sensitivity and 66.7% specificity. Conclusion: High proportion of borderline ALNs are not malignant. Strain elasticity can improve the risk stratification of such cases and prevent unnecessary invasive procedures. We suggested an algorithm that could better tackle borderline ALN which will need further evaluation

Clinical Course of Bacillus Calmette-Guerin Lymphadenitis.

Bacillus Calmette-Guerin (BCG) vaccination can cause lymphadenitis. The purpose of the current study was to describe patient characteristics and clinical courses of lymphadenitis associated with BCG vaccination. A total of 171 patients who visited a tertiary hospital with a diagnosis of BCG-associated lymphadenitis between January 2012 and June 2017 were included. The diagnostic criteria were a history of BCG vaccination on the symptomatic side, absence of tenderness and raised temperature over the swelling, absence of fever and constitutional symptoms, and isolated axillary (or supraclavicular/cervical) lymph node (LN) enlargement. Treatment strategies included observation, antibiotics, incision and drainage or needle aspiration (I&D/NA), and surgical excision. The median follow-up period was 40 days (range 1–1245 days). The median age at the first visit was 5.5 months (range 0.9–83.7 months). The most common location was the axilla (81.3%). The respective numbers of patients managed via observation, I&D/NA, antibiotics, and surgical excision were 99, 47, 5, and 20. LNs were significantly more enlarged in the I&D/NA group than in the antibiotics group and the observation group. The respective times taken for residual lesions to reduce to < 20% were approximately 3 months, 4 months, and 5 months in the antibiotics, observation, and I&D/NA groups. The surgery group had significantly fewer residual lesions than the observation group at the last visit, but there was no significant difference in current residual lesions between the groups. LNs were significantly larger in the I&D/NA group. The surgery group exhibited the least residual lesions at the last visit, but there was no significant difference in current status.

Lymphadenopathy in the era of COVID-19 vaccination – an oncological dilemma in diagnostic imaging

Initial clinical experience with COVID-19 vaccination suggests that approved COVID-19 mRNA vaccines induce a strong immune response and thus cause a significantly higher incidence of axillary lymphadenopathy compared with other vaccines. It can therefore be expected to complicate the diagnosis of patients with overt or suspected mali-gnancy, in whom it may be indistinguishable from malignant node involvement. There is a need for guidelines on the appropriate management of unilateral axillary lymph node enlargement. This article studies the available reports on vaccine-associated lymphadenopathy. It also presents a basic strategy for the assessment of axillary lymphadenopathy based on preliminary recommendations and an algorithm. According to these recommendations, screening should be scheduled before or at least 4-6 weeks after the last dose of the vaccine. This will allow reactive adenopathy to resolve and avoid unnecessary and costly axillary lymph node biopsy. Clear and effective communication between patients, radiologists, referring physician teams, and the general public is the way forward in the management of adenopathy following COVID-19 vaccination.Herein we present 5 cases of lymph node enlargement after mRNA vaccine administration from different authors. Their initial radiological diagnosis raised concerns that they might be metastases. Therefore, radiologists need to include COVID-19 vaccination in the differential diagnosis of patients with unilateral axillary adenopathy. Short-term follow-up of unilateral axillary adenopathy with recent COVID-19 vaccination is an appropriate recommendation.

TAFRO syndrome: A case report with biopsy findings from three sites

Abstract Introduction/Objective TAFRO syndrome (thrombocytopenia, anasarca, fever, reticulin fibrosis, and organomegaly) is a rare systemic inflammatory disorder. First reported in 2010, the majority of cases are from Japan, where it is currently regarded as a subtype of HHV8-negative Multicentric Castleman Disease. Methods/Case Report We report a case of TAFRO occurring in a 17-year old from Puerto Rico. She originally presented with abdominal pain, vomiting, and fever, and was also found to have splenomegaly, elevated sedimentation rate and C-reactive protein. Over the course of the next several days she developed respiratory distress, requiring ventilatory support, and anuric renal failure. Renal biopsy demonstrated evidence of thrombotic microangiopathy, which was interpreted as atypical hemolytic syndrome, requiring dialysis and treated with eculizumab. Because other diagnostic considerations at the time also included hemophagocytic lymphohistiocytosis and catastrophic antiphospholipid syndrome, bone marrow examination was performed which demonstrated increased megakaryocytes, without fibrosis or hemophagocytosis. Over the next two months, she developed anasarca with ascites, pleural effusion, pericardial effusion, multiple enlarged axillary and cervical lymph nodes, and persistence of splenomegaly. Biopsy of a left cervical lymph node demonstrated features suggestive of Castlemans disease, plasma cell variant. The constellation of symptoms, laboratory investigations and biopsy diagnoses support the diagnosis of TAFRO syndrome. The patient received rituximab, high dose steroids, and hemodialysis with clinical improvement. At 16 months follow up, the patient is in remission. Results (if a Case Study enter NA) NA Conclusion From a pathology standpoint, the case provides biopsy findings of three distinct organ systems all with relatively unusual findings that together are characteristic of TAFRO syndrome. It highlights the risk of accepting “biopsy proven” diagnoses such as atypical hemolytic uremic syndrome that also require significant laboratory and clinical correlation for true confirmation, and points out the importance and opportunity for pathologists to see the forest along with the trees in order to recognize rare diseases such as TAFRO.

Adult-onset Still\u2019s disease with multiple lymphadenopathy: a case report and literature review

BackgroundAdult-onset Still’s disease (AOSD) often presents with systemic multiple lymphadenopathy. In addition to the common paracortical and mixed patterns in AOSD lymph node histopathological features, other morphological patterns include diffuse, necrotic, and follicular patterns. However, to date, there have been few reports on the histopathological description of AOSD lymph nodes.Case presentationAn 18-year-old woman presented 2 months earlier with pain in her large joints with painless rash formation; bilateral posterior cervical lymph node, left supraclavicular lymph node, and left posterior axillary lymph node enlargement, and no tenderness. Left cervical lymph node resection was performed for pathological examination. The lymph node structure was basically preserved, and subcapsular and medullary sinus structures were observed. Many histiocytes in the sinus were observed, the cortical area was reduced, a few lymphoid follicles of different sizes were observed, and some atrophy and hyperplasia were noted. The lymphoid tissue in the paracortical region of the lymph node was diffusely proliferative and enlarged, mainly comprising histiocytes with abundant cytoplasm, immunoblasts and numerous lymphocytes with slightly irregular, small- to medium-sized nuclei. Nuclear karyorrhexis was easily observed, showing a few nuclear debris and the “starry sky” phenomenon, accompanied by abundantly branching high endothelial small vessels with few scattered plasma cells and eosinophil infiltration. Lymphoid follicle immunophenotype with reactive proliferative changes was observed. Approximately 40% of the cells in the paracortical region were positive for Ki-67, and the histiocytes expressed CD68, CD163, and some expressed S-100, with the absence of myeloperoxidase. The immunoblasts expressed CD30 and CD20, not ALK or CD15. Background small- to medium-sized T cells expressed CD2, CD3, CD5, CD7, CD4, and CD8; the number of CD8-positive T cells was slightly predominant, and a small number of T cells expressed granzyme B and T-cell intracellular antigen 1. The patient received a comprehensive medical treatment after the operation, and her condition was stable without progression at the 11-month follow-up evaluation.ConclusionsThe pathological features of AOSD lymphadenopathy raises the awareness of AOSD among pathologists and clinicians and aids in the diagnosis and differential diagnosis of AOSD lymphadenopathy from other reactive lymphadenopathies (lupus lymphadenitis, etc.) and lymphomas.

COVID-19 Vaccination-Related Uptake on FDG PET/CT: An Emerging Dilemma and Suggestions for Management.

As mass COVID-19 vaccination is underway, radiologists are encountering transient FDG uptake in normal or enlarged axillary, supraclavicular, and cervical lymph nodes after ipsilateral deltoid vaccination. This phenomenon may confound interpretation in patients with cancer undergoing FDG PET/CT. In this article, we present our institutional approach for management of COVID-19 vaccine-related lymphadenopathy on FDG PET/CT according to early experience. We suggest performing PET/CT at least 2 weeks after vaccination in patients with a cancer for which interpretation is anticipated to be potentially impacted by the vaccination but optimally 4-6 weeks after vaccination given increased immunogenicity of mRNA vaccines and potentially longer time for resolution than lymphadenopathy after other vaccines. PET/CT should not be delayed when clinically indicated to be performed sooner. Details regarding vaccination should be collected at the time of PET/CT to facilitate interpretation. Follow-up recommendations for postvaccination lymphadenopathy are provided, considering the lymph node's morphology and likely clinical relevance. Consideration should be given to administering the vaccine in the arm contralateral to a unilateral cancer to avoid confounding FDG uptake on the side of cancer. Our preliminary experience and suggested institutional approach should guide radiologists in management of patients with cancer undergoing PET/CT after COVID-19 vaccination.