Left Inguinal Lymphadenopathy Research Articles

FDG PET/CT in Staging and Response Evaluation of Primary Urothelial Carcinoma of the Urethra.

Primary urethral urothelial carcinoma is a rare aggressive tumor with a high propensity for local invasion and regional and distal metastases. We describe the usefulness of FDG PET/CT in management of a patient with primary urethral urothelial carcinoma. FDG PET/CT at initial staging showed FDG-avid primary tumor and lymph node metastasis of the left groin, and mild or no activity of the lung metastases due to small size. FDG PET/CT after 4 cycles of chemotherapy showed progression of the primary tumor and lung metastases, partial response of the left inguinal lymphadenopathy, and multiple new sites of FDG-avid metastases.

Inguinal Lymphadenopathy After Renal Transplantation Leading to the Diagnosis of Prostate Cancer: A Case Report

It is extremely rare for a patient with prostate cancer (PCa) to have palpable lymph nodes at the initial presentation. In fact, only 4 case reports of palpable superficial lymph nodes at the first visit led to the diagnosis of PCa. Moreover, no such cases are reported in kidney transplantation (KT) patients. A 72-year-old man who started hemodialysis due to diabetic nephropathy was referred to our hospital for a KT in 2018. Before the KT, he had a negative screen for cancer, including PCa. The postoperative course was good. He felt a lump in the left inguinal region three years after the KT. A computed tomography scan revealed abdominal and left inguinal lymphadenopathy, which was consistent with a post-transplant lymphoproliferative disorder. However, a biopsy of an inguinal lymph node revealed adenocarcinoma with positive prostate-specific antigen (PSA) staining, suggesting lymph node metastasis of PCa. The blood PSA level was 1674.23 ng/mL. A prostate biopsy was performed, the pathologic diagnosis of which was PCa, with a Gleason score of 10. In conclusion, even though the standardized incidence ratio of PCa is not known to increase in KT patients, PCa should be included in the differential diagnosis, along with the possibility of post-transplant lymphoproliferative disorder. We also suggest the importance of regular screening for malignant tumors after organ transplantation.

ODP094 Hypercalcemia caused by Mycobacterium Avium Complex, with Excellent Response to Intravenous Pamidronate.

Abstract Background Hypercalcemia caused by granulomatous diseases such as sarcoidosis and tuberculosis, is a well-recognized entity. The pathophysiology of hypercalcemia associated with granulomatous diseases is related to increase conversion of 25 hydroxyvitamin D to its active form, 1,25 dihydroxyvitamin D, via extra-renal 1 -α hydroxylase activity. We present a patient with moderately sever hypercalcemia caused byMycobacterium Avium complex (MAC) infection in association with Human Immunodeficiency Virus (HIV) infection. Case Presentation The patient is 53-year-old male with longstanding HIV infection since 2003. He was referred to the endocrine clinic after an acute presentation to a local hospital in August 2021 with pancytopenia, lymphadenopathy, and hypercalcemia (corrected total calcium 13.8 mg/dl) with acute kidney injury. He was treated with intravenous fluids and subcutaneous Calcitonin injection. Endocrine work up showed low parathyroid hormone (PTH) at 3 pg/ml (14-95 pg/ml) and Parathyroid related peptide (PTHrP) level was <0.4 pmol/l. His 1,25 dihydroxy-vitamin D was elevated at 172 pg/ml (18-64 pg/ml) . Computed Tomography (CT) study for neck, chest and abdomen showed hepatosplenomegaly, generalized lymphadenopathy involving the left cervical area, left supraclavicular area, mediastinal, retroperitoneal, mesenteric and inguinal lymphadenopathy. Bone marrow study from August 2021 showed no evidence of leukemia, lymphoma, tuberculosis or other bone marrow inflammatory or infiltrative processes. Left sided neck lymph node biopsy showed diffuse granulomatous disease and numerous acid-fast organism consistent with Mycobacterium Avium complex (MAC) He was treated with azithromycin 250 mg daily, ethambutol 1200 mg daily, and rifabutin 300 mg daily in addition to anti-retroviral therapy (bictegravir/emtricitabine/tenofovir). Hypercalcemia was treated with one dose of pamidronate 90 mg which normalized serum calcium within one week. Glucocorticoids was not considered due to concerns over sever immunosuppression due to HIV/ AIDS and pancytopenia. Denosumab, ketoconazole and hydroxychloroquine were also not considered due to concerns over side effects. His 1,25 dihydroxy-vitamin D level normalized after four months from starting treatment with anti MAC therapy. Most recent calcium level 9.1 mg/dl, with 1,25 dihydroxy-vitamin D level of 31 pg/ml. Conclusion Mycobacterium Avium Complex infection is a possible cause of hypercalcemia, especially in immunocompromised individuals. Glucocorticoids, usually the first line treatment for acute hypercalcemia induced by 1,25 dihydroxyvitamin D overproduction, might not be appropriate in all patients. Alternatives include hydroxychloroquine, ketoconazole and parenteral bone anti- resorptive agents. Our patient had an excellent response to one dose of pamidronate. Ultimately his1,25 dihydroxy-vitamin D normalized with effective anti MAC therapy. Presentation: No date and time listed

S2191 A Case Report of Syphilitic Proctitis Mimicking Rectal Cancer

Introduction: Syphilis rarely affects the gastrointestinal tract, and even more rarely manifests with lower gastrointestinal signs and symptoms. We report a rare case of syphilitic proctitis that presented with inguinal lymphadenopathy and pain with defecation mimicking anorectal malignancy. Case Description/Methods: A 31-year-old male with a history of multiple, recent male sexual partners, sexually transmitted infections (STIs), anxiety, depression, and migraines presented to the emergency department with a 2-month history of left inguinal pain, perianal pain, and pain with defecation. His initial exam was notable for a palpable rectal mass and tender left inguinal lymphadenopathy. CT abdomen/pelvis demonstrated a markedly enlarged left inguinal lymph node measuring 3.9 x 2.7 x 3.1 cm with multiple enlarged perirectal and left internal iliac lymph nodes, radiographically concerning for metastatic disease. Colonoscopy revealed congested mucosa in the rectum and a palpable external rectal mass on digital rectal exam. He was tested for sexually transmitted diseases and was found to have a reactive RPR with a titer of 1:128 and positive T. pallidum antibodies. His biopsy resulted with findings of syphilitic proctitis and spirochetosis confirmed by treponema pallidum immunostain, consistent with secondary syphilis. He was treated with a 14-day course of doxycycline (due to penicillin allergy) with initial improvement in symptoms. Discussion: Syphilis is an important public health issue with increasing cases in the United States over the last 20 years. Syphilis uncommonly affects the gastrointestinal tract, and even less commonly the lower GI tract. Syphilitic proctitis most often presents with pain on defecation, rectal bleeding, tenesmus, and diarrhea and is often difficult to distinguish from inflammatory bowel disease or malignancy. Given the rise in sexually transmitted infections, it is important for providers to be aware of this presentation, which requires a thorough sexual history and prompt testing if exposure is suspected, to prevent ongoing transmission and development of complications. Our case highlights the rare presentation of syphilis and the importance of screening for STIs in high-risk patients.

Chest Wall Mass as the Dominant Presentation of Low-Grade B-Cell Non-Hodgkin's Lymphoma: A Case Report.

Low-grade B cell non-Hodgkin's lymphoma with dominant presentation of chest wall mass is presented in this report. The patient, a 65-year-old woman, presented with pain, rising skin temperature and redness, and swelling on the right lower chest wall. The histopathological examination revealed non-Hodgkin's lymphoma; the staging fluorodeoxyglucose-positron emission tomography/computed tomography demonstrated stage IVE disease, with hypermetabolic active disease in the right anterolateral chest wall in the form of large soft tissue mass and subcutaneous tissue with underlying bony erosion with extension into right anterior cardiophrenic space and superiorly up to right second costosternal region along the right internal mammary vessels. This was along with hypermetabolic active right axillary, right supraclavicular and left inguinal lymphadenopathy, and thickened hypermetabolic posterior right pleura with ametabolic right-sided pleural effusion. Bone marrow biopsy revealed uninvolved bone marrow. On follow-up after eight cycles of R-CHOP chemotherapy, the mass had completely resolved on contrast-enhanced computed tomography.

A PECULIAR CASE OF ISOLATED METASTATIC INGUINAL LYMPHADENOPATHY IN A YOUNG LADY – A CASE REPORT

Lymphadenopathy refers to the swelling of lymph nodes which can be secondary to bacterial, viral or fungal infections, autoimmune disease and malignancy. Lymphadenopathy can be localized or diffuse. About 75% of most lymphadenopathies are localized, and about 50% of those occur in the head and neck regions . Inguinal lymphadenopathy (3) occurs at the groin region and most common causes include infections of leg or foot, STDs, non Hodgkin's lymphoma, tuberculosis and pelvic malignancies. One of the rare causes includes distant metastasis of nasopharyngeal carcinoma (NPC) which is present in our case. Nasopharyngeal cancer is an uncommon squamous cell carcinoma in the head and neck region, in most parts of the world. It has a high propensity for lymphatic spread and is known for regional metastases with occult primary at presentation . The incidence of distant (1) metastasis at presentation ranges from 4.4 to 6%. The most common sites of metastasis are bone (70%–80%) followed by liver (30%), lungs (18%) and distant lymph nodes (axillary, mediastinal, pelvic and inguinal, in that order) . About 98% of them are discovered within 3 (2) years of treatment. As it is a highly chemo and radio-sensitive tumor, radiotherapy with concurrent chemotherapy is the mainstay in the management of local and advanced diseases. Here we are presenting a peculiar case of previously treated NPC presenting as isolated left inguinal metastatic lymphadenopathy in a young lady

Multiple CNS Tumors in a Patient With Neurofibromatosis Type 2: Classical Presentation of a Rare Disease

Neurofibromatosis type 2 is a genetic autosomal dominant disorder caused by a spontaneous mutation in the gene located on chromosome 22 q11-13.1, which usually emerges in adolescence or early adulthood and is characterized by the development of bilateral vestibular schwannoma. We hereby report the classical case of Neurofibromatosis type 2 in a 25-year-old young male with multiple tumors associated with the disease. This patient presented to us with 3 years history of multiple painless nodules on his skin, facial weakness, left-sided progressive hearing loss, and 20 days history of weakness in the left lower limb. On Examination, he was vital with a GCS of 15/15. He was anemic with no jaundice. He had left inguinal lymphadenopathy along with multiple subcutaneous nodules on different areas, including the scalp, face, left mid-axillary line over the abdomen. He also had Right-sided facial palsy and horizontal nystagmus. CNS examination revealed an upgoing plantar on the left side, right facial nerve palsy, and bilateral vestibulocochlear nerve paralysis. Spine examination revealed spinal tenderness in the lower lumbar region. Superficial abdominal reflexes were absent. Upper limb and right lower limb power, tone, and reflexes were normal while the tone and power in the left lower limb were reduced power being ⅗. Reflexes were also exaggerated in the left lower limb. The right ankle showed swelling, most probably a plexiform neuroma. On investigations, he had normochromic normocytic anemia with mild leucocytosis. Platelets were normal. The rest of the biochemical investigations, including serum electrolytes, liver function tests, and renal function tests, were also normal.MRI brain and spine confirmed bilateral acoustic neuroma and multiple cranial and peripheral nerve tumors i.e., classical presentation of a rare disease neurofibromatosis. He was referred to the neurology unit for further assessment and treatment.

Pediatric Bartonella Infection (Cat Scratch Disease) Presenting as Inguinal Lymphadenopathy

Cat scratch disease is an infectious disease resulting from inoculation of Bartonella species through a cat scratch or bite, often presenting as an erythematous papule at the site of inoculation with nearby painful lymphadenopathy. The diagnosis of this disease is complicated by a wide variety of clinical presentations, as the primary lesion may not be initially noticed. Furthermore, cervical and axillary lymph nodes are the most commonly involved regions of tender lymphadenopathy, but there have been reported cases that do not fit the typical clinical picture – such the case discussed in this report of a pediatric Bartonella henselae infection that initially presented as left inguinal lymphadenopathy with underlying necrosis and abscess formation. In this case, a 9-year-old boy presented to the ED with a 4-day history of increasing mass in the left groin, as well as a subjective fever for the previous 2 days. An ultrasound revealed a necrotic abscess in the left inguinal lymph node which necessitated empiric antibiotic therapy and surgical excision; titers revealed a recent infection with Bartonella henselae. Atypical presentations of cat scratch disease, such as inguinal lymphadenopathy, have historically confounded the diagnosis. However, positive serology studies ultimately yielded the correct diagnoses in these children. Given that cat scratch disease can present in an atypical fashion in approximately 5 - 25% of cases, physicians should keep the disease on the differential even when presented with rare presentations such as inguinal lymphadenopathy; serological testing for B. henselae can be utilized once more likely etiologies have been ruled out.

Inguinal lymph node metastasis as the only manifestation of recurrent ovarian cancer: a case report

Background: Ovarian cancer has emerged as one of the most common malignancies affecting women in India. Despite optimal surgery and appropriate first-line chemotherapy, almost 70%–80% of patients with epithelial ovarian cancer will develop recurrence. Inguinal lymph node metastasis is a rare site of involvement in recurrent epithelial ovarian cancer. Case Presentation: Herein, we report the case of a 54-year-old female who presented to us with painless left inguinal lymphadenopathy. She gave history of being diagnosed with malignant ovarian cancer 2 years ago, for which she underwent debulking surgery. She received only one cycle of chemotherapy after which she defaulted. Cytological examination of the inguinal nodes revealed metastatic ovarian cancer. CA-125 levels were elevated despite the lack of any foci of metabolically active tissue on imaging. Conclusion: Inguinal lymphadenopathy is a rare presentation of recurrent ovarian cancer. Despite that, it is essential to examine the inguinal region in the follow up of all the cases of ovarian cancer. It is also necessary to consider ovarian cancer in the differential diagnosis for inguinal lymphadenopathy in a female patient.

Recurrent isolated tuberculous inguinal lymphadenopathy : A case report and review of literature

Chronic peripheral lymphadenopathy is indicative of pathology of which tuberculosis is the commonest. Isolated inguinal tuberculous lymphadenitis is a rare finding. Presented is a healthy looking 16 year old human immunodeficiency virus seronegative male with recurrent isolated tuberculous left inguinal lymphadenopathy. Physicians are requested to consider tuberculosis as differential diagnosis of inguinal lymphadenopathy and to subject same to histological evaluation for proper diagnosis and treatment.

Réaction paradoxale à la fin du traitement antituberculeux chez le sujet immunocompétent

The features of paradoxical reactions (PR) that occurred in non-HIV infected patients are rare and not well known. The authors reported the case of a 21years old, non-immunocompromised, and HIV negative patient treated for disseminated tuberculosis. PR occurred after 8months after initiation of antituberculous treatment. PR presented as left cervical lymphadenopathy, pulmonary, pleural, costal and spinal location of the tuberculosis. The antituberculous drugs were prolonged. Patient's clinical symptoms improved initially. However, left inguinal lymphadenopathy appeared after 20months of antituberculous therapy. Inguinal lymph node biopsy revealed tuberculous lymphadenitis. The patient has a good compliance to the treatment. The patient was continued on same antituberculous treatment for a total of 28months. The cervical and inguinal lymphadenopathy disappeared and CT scan showed regression of thoracic, abdominal, costal and spinal lesions. PR during antituberculous treatment must be considered after exclusion of other causes. No consensus on the therapeutic management of this entity has been developed to date.

A Rare Case of Unusual Malignant Melanoma

This report presents a case of “Advanced anal verge melanoma with secondaries in left inguinal lymph node , liver and vesico-uterine angle”. A 55year old female presented with complain of bleeding per rectum for 2 years and mass coming out through anus for 8 days. Local examination revealed a pedunculated lobular growth from the perianal verge with blackish discolouration along with left inguinal lymphadenopathy. On ultrasonography and CT Scan metastatic deposits in liver and vesicouterine angle was detected. This case report demonstrates the aggressive nature of the disease and hence gives a message to have a high index of suspicion for any case of rectal bleeding with lightly pigmented or non pigmented polypoid lesion on proctoscopic examination for early diagnosis and treatment. BACKGROUND

Abstract 4309: Description of a scientific treatment approach of mast cell leukemia, an aggressive orphan hematologic disorder: strategy based on next-generation sequencing data

Abstract Background Mast cell leukemia (MCL) is the most aggressive form of disorder among systemic mastocytosis. Due to its rarity, neither pathogenesis nor standard treatment is not established for this orphan disease. Hence, we tried to treat a patient with MCL based on the exome and transcriptome sequencing result of the patient's own DNA and RNA. Brief Case History and Results In October 2013, an 18-year-old Korean female were diagnosed as MCL after visiting our hospital due to left knee, ankle pain and inguinal lymphadenopathy. C-KIT overexpression was observed by immunohistochemistry. Whole exome sequencing result failed to demonstrate either noticeable single nucleotide variant (SNV) or copy number change. Interestingly, whole transcriptome sequencing (WTS) revealed mutation of KIT S476I, functionality of which is not known. Fusion analysis was performed using WTS data, possibility of RARα-B2M fusion has been arised. However, it was not validated by PCR sequencing. When RNA expression analysis was performed using WTS data, upregulation of PIK3/AKT pathway, which is a downstream of KIT (BAD phosphorylation) and mTOR has been observed. For the treatment perspective, she failed to achieve complete remission after cytarabine and idarubicin chemotherapy. Based on our WES and WTS result, we first tried all-trans retinoic acid targeting RARα, which failed to demonstrate efficacy. Then, she received dasatinib targeting KIT, which showed transient response for 2 weeks. Now she is under everolimus targeting mTOR pathway and, further treatment with PI3K inhibitor is planned in case of disease progression. Conclusions We are demonstrating a case of orphan disease, where we used targeted approach using WES and WTS data of the patient. Final results of our treatment outcome will be uncovered shortly, and utility of this kind of approach is to be validated. Citation Format: Jeonghwan Youk, Youngil Koh, Ji-Won Kim, Dae-Yoon Kim, Woo June Jung, Kwang-Sung Ahn, Sung-Soo Yoon, Hye Lim Jung. Description of a scientific treatment approach of mast cell leukemia, an aggressive orphan hematologic disorder: strategy based on next-generation sequencing data. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4309. doi:10.1158/1538-7445.AM2015-4309

Left inguinal lymphadenopathy as the solitary metastatic presentation of primitive neuroectodermal tumor of unknown origin

Primitive neuroectodermal tumor (PNET)/ewing's sarcoma is a rare neural crest tumor of central nervous system, thoracopulmonary regions, pelvis, and lower extremities. Visceral involvement by PNET is a rare phenomenon, with kidney being the most commonly involved organ. We report a 35-year-old Asian female presenting with left inguinal swelling, with computed tomography scan evidence of conglomerate lymph nodal mass in the left external iliac and inguinal region. A clinico-radiological diagnosis of lymphoproliferative disorder was made. She subsequently underwent excision biopsy. Histopathology of the biopsy specimen revealed completely effaced lymph nodal architecture, which was replaced by a tumor composed of nests of small, round, blue cells. On immunohistochemistry, the tumor cells were positive for CD99 and negative for CD3, CD20, leucocyte common antigen, epithelial membrane antigen, cytokeratin, desmin, vimentin, synaptophysin, and chromogranin A. Extensive search regarding any possible different site of involvement by the tumor was negative. The clinical presentation and histological, cytological, and immunohistochemical pattern, lead to the diagnosis of metastatic PNET of the left external iliac and inguinal lymph node with unknown primary origin. To the best of our knowledge, it is the first ever reported case of inguinal lymphadenopathy as the solitary metastatic presentation of PNET of unknown origin.

Ultrasound-Guided Peri-Lymphatic and Peri-Neural Corticosteroid Injection as an Adjuvant to Pain and Lymphedema Management in Terminal Cancer: Two Case Reports

We are reporting two patients presented with intractable cancer pain that was treated with a novel application of an ultrasound-guided peripheral nerve block using corticosteroid. This technique offered relief to both patients whom otherwise their cancer pain was difficult to manage. The first patient developed lymphedema to the right axilla from metastatic squamous cell carcinoma. After multiple injections were deposited around the brachial plexus, lymphedema on the right axilla decreased slightly in size; however, range of motion improved post-procedure prior to his discharge one week later. In the second patient with left inguinal lymphadenopathy from metastatic left ureteral transitional cell carcinoma, there was a dramatic reduction in lymphedema in the left groin and leg as well as a considerable decrease in pain score during a two week follow-up after the peri-neural and peri-lymphatic femoral block. A 75% improvement in patient satisfaction was reported in the office visit’s questionnaire form. Corticosteroids can be used as an adjuvant to peripheral nerve block to decrease the pain secondary to lymphedema caused by the inflammatory response from metastatic cancer. This application can provide an alternative way to manage severe cancer-related pain caused by lymphedema in both upper and lower limbs.

A case of metastatic prostate adenocarcinoma to an inguinal lymph node

A 47-year-old man presented with dysuria. The prostate-specific antigen level was 65.5 ng/mL. Retropubic radical prostatectomy and regional lymphadenectomy revealed moderately differentiated adenocarcinoma (Gleason score 3 + 4 = 7, pT2N0). Postoperative adjuvant hormonal therapy was started immediately. Three years later, hormonal therapy was changed to anti-androgen monotherapy. Monotherapy was continued for eight years and then discontinued because the PSA level was maintained at <0.04 ng/mL. However, biochemical recurrence occurred 12 months after adjuvant hormonal therapy was discontinued. A computed tomography scan showed left inguinal lymphadenopathy. Biopsy of the swollen inguinal lymph node revealed metastatic prostate cancer. We report a rare case of metastatic prostate adenocarcinoma only to the inguinal lymph nodes.

Tuberculosis in the left inguinal region associated with cutaneous tuberculosis of left second toe: An unusual presentation of extrapulmonary tuberculosis

We report an uncommon case of tuberculosis involving left second toe associated with left inguinal lymphadenopathy and an ulcer in a 30-year-old male with no other pulmonary or extra pulmonary tubercular infection. Diagnosis was made by biopsy. He responded very well to anti tubercular treatment.

Peripheral T cell lymphoma, NOS, with hodgkin reed-sternberg-like cells: a diagnostic dilemma

A diagnosis of peripheral T cell lymphoma (PTCL), not otherwise specified (NOS), on tissue samples is made after excluding specific types of PTCL. Although uncommon, PTCL, NOS can be associated with Hodgkin Reed-Sternberg (HRS)-like cells which can result in a misdiagnosis of classical Hodgkin lymphoma. While the HRS-like cells may be part of a reactive B cell population infected by Epstein-Barr virus (EBV)inPTCL, composite lymphoma comprising PTCL, NOS and classical Hodgkin lymphoma has been described. The ability to separate markedly reactive EBV infected B cells in the setting of a PTCL and a composite lymphoma with T cell and classical Hodgkin lymphoma can be exceedingly difficult. In this report, we detail an instance of PTCL with HRS-like cells affecting a 56-year-old Chinese female who presented with left inguinal lym-phadenopathy associated with constitutional symptoms for the previous month. The lymph node disclosed effacement by a neo-plastic T cell population, with loss of CD5 and CD7 expression in association with HRS-like cells disclosing atypical mitotic forms. The criteria for separating a composite lymphoma and a PTCL with reactive HRS-like cells, and problematic issues in achieving a correct diagnosis, are presented.

Minimal-change nephrotic syndrome preceding Hodgkin lymphoma by 5 years with expression of tumor necrosis factor α in Hodgkin-Reed-Sternberg cells

A 76-year-old man developed minimal-change nephrotic syndrome (NS). After treatment with prednisolone failed to induce sustained remission, cyclosporin was added. The NS improved, and prednisolone and cyclosporin doses were gradually decreased. However, he had repeated relapses of the syndrome, and at each relapse, the drug doses were increased. After 5 years, the patient developed left inguinal lymphadenopathy. The histological diagnosis was mixed cellularity classical Hodgkin lymphoma. He received 6 courses of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine), and mixed cellularity classical Hodgkin lymphoma and NS both showed complete response. Although the association between Hodgkin lymphoma and minimal-change NS is well known, the pathogenesis is unknown. To the best of our knowledge, this is the first case report of minimal-change NS associated with Hodgkin lymphoma in which Hodgkin-Reed-Sternberg cells were immunostained for tumor necrosis factor-alpha (TNF-alpha) clearly demonstrating that Hodgkin-Reed-Sternberg produced TNF-alpha and in which the plasma level of TNF-alpha normalized after improvement of Hodgkin lymphoma by chemotherapy. The production of TNF-alpha by Hodgkin-Reed-Sternberg cells might play a key role as a potential mediator of minimal-change NS.

African Tick-Bite Fever

A 62-year-old man presented to our institution with a 1week history of a nonpruritic rash on his left leg, lowgrade fever, and tender inguinal adenopathy. He had traveled to the African countries of Malawi and Zambia for sight-seeing and a safari during the month before onset of symptoms. He denied any insect exposure but used no specific topical prophylaxis. On examination, the patient appeared well; his temperature was 36.8°C. He had tender left inguinal lymphadenopathy. An approximately 1-cm black eschar was evident just below his left knee (Figure) along with a large area of erythematous skin and a petechial nonblanching rash. There was associated lymphangitic streaking extending up toward the inguinal area and pronounced unilateral pitting edema. The adenopathy resolved within 2 days of initiation of doxycycline therapy. After approximately 1 week, the rash began to fade, and the lymphedema resolved. A serologic test for Rocky Mountain spotted fever (RMSF) was positive at 1:512. Because RMSF is not endemic to Africa, other specific rickettsial serologic tests were requested from a research laboratory. These revealed an initial Rickettsia africae IgG of 1:32 with an IgM of 1:8; analysis 1 month later revealed an IgG of 1:256. Other rickettsial serologic tests were negative. African tick-bite fever (R africae) is an increasingly common and appreciated cause of illness in travelers returning from Africa. In a recent study, 27% of patients returning from sub-Saharan Africa with fever were found to have R africae infection. The infection is spread by the Amblyomma tick, a notoriously aggressive tick that is associated with wild game but may be found on vegetation. Common clinical characteristics are fever, headache, myalgias, lymphadenitis, and an inoculation eschar with cutaneous rash—the classic tache noire. No readily available serologic diagnosis exists except in research laboratories, although a serologic test for RMSF will occasionally be positive. The infection is usually self-limited but can be treated with oral doxycycline.