Medical Mystery of the Week
You are asked to examine a 73-year-old woman who presents with a two-week history
of a progressively enlarging mass in her right groin associated with daily fevers
as high as 38.3°C accompanied by drenching night sweats.
On physical examination her temperature is 37.4°C, pulse 84 beats/min, respiratory
rate 18 breaths/min, and blood pressure 140/63 mmHg. Her spleen is palpable and there
are multiple right and left inguinal nodes (2-5 cm and 1-2 cm in maximal diameter,
respectively). The nodes are hard, nonmotile, and slightly tender. No adenopathy is
detected in the occipital, cervical, or axillary areas.
Pertinent laboratory findings include a normochromic normocytic anemia (Hct
29.1%, HGB 9.4 g/dl), a leukocytosis of 17,900 wbcs per mm3 with 68.7% lymphocytes, 26.1% neutrophils, 2.6% monocytes, and 2.6% eosinophils.
Her liver chemistries and measurements of renal function are normal. The results of
a PET scan and a fused PET-CT scan are shown below.
What is your diagnosis, what test(s) would you order to confirm your suspicions,
and what treatment, if any, do you recommend?
DIAGNOSIS: Herpes simplex lymphadenitis in a patient with chronic lymphocytic
leukemia (CLL).
CLL is the commonest leukemia in western countries. The disease typically occurs
in elderly patients and has a highly variable clinical course. Leukemic transformation
is initiated by specific genomic alterations that impair apoptosis of clonal B- cells.
The diagnosis of CLL is established by blood counts, blood smears, and immunophenotyping
of circulating B lymphocytes, which identify a clonal B-cell population carrying the
CD5 antigen, as well as typical B-cell markers. Treatment options are included in
the cited article.
Herpes simplex virus type I and II are common infections involving the lips
and genitalia. In this regard, inguinal nodes drain the ipsilateral leg, genitalia,
buttoch, pelvis, and abdominal wall below the umbilicus with the genitalia being the
presumed source of lymph node infection in the presented case.
A fused PET-CT scan shows marked uptake of 18F-fluorodeoxyglucose in the right inguinal node (left image). H&E staining of an excisional node biopsy shows viral cytopathic effects including multinucleation & nuclear molding (arrow) and chromatin margination (arrowhead) (middle image). Immunohistochemical staining of the node shows the presence of both HSV type I and HSV type II (right image).
Citation: Hallek M. Chronic lymphocytic leukemia: 2020 update on diagnosis, risk stratification and treatment. Am J Hematolol. 2019;94:1266-1287.
a.
The PET and PET-CT scans show marked increased uptake of 18F-fluorodeoxyglucose (FDG) in the right ingunal nodes (arrows).
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