Case

1
Case 2

• 52 yo woman with only significant PMH of Fe def
  anemia and total hysterectomy for menorrhagia
• Teacher, previously taught in Mississippi on the
  delta and several Indian Reservations
• Recently took a job as a teacher for the children
  of the Kuwaiti Emir (1/01)
• In Kuwait and Jordan for 18 months

2
Case 2 Continued

• While in Kuwait and Jordan, primarily in the
  cities, but in Jordan occasionally in more rural
  areas
• Stayed one night in a Bedouin tent
• Next morning she awoke with an apparent bite on
  her neck
• Lesion slowly enlarged, looked like ringworm to
  the size of a dime
• Two weeks later developed a similar lesion on her
  right breast

3
Case 2 continued

• Saw MD in Kuwait who biopsied the breast lesion,
  told her it was ok, but recommended she get it
  checked when she returned to the U.S.
• Returned to the U.S. in 6/02 and in 8/02
  developed high fevers and cervical
  lymphadenopathy
• Accompanied by sweats, soaked her bed clothes
  every night

4
Case 2 continued

• Saw primary MD who referred her to a surgeon
• 9/10/02 lymph node biopsy
• suppurative granulomatous lymphadenitis
• AFB, GMS, Warthin-Starry stains all negative
• Treated with two different courses of Amox-clav
  without much change
• PPD done x 2 and (-)
• A little better over the next few weeks, but
  still with fever, night sweats, soaked her bed
  clothes 1-2 / wk
• Referred to ID at WFUBMC

5
Case 2 continued

• PMH as stated
• HIV tested before she went to Kuwait and (-)
• Meds
• Premarin, Celexa
• NKDA
• FMH
• Brother with HIV
• Mother and Father with heart disease, DM

6
Case 2 continued

• Soc Hx
• Other exposures one year old cat received in
  Jordan, brought home
• Met and married an assistant to King Abdulla in
  Jordan Chechyn (??) Muslim
• First sexual encounter in 15 yrs on their wedding
  night 2 weeks before her return to the U.S.
  included oral-genital contact
• ROS
• Completely negative except fever, chills, sweats,
  adenopathy
• Weight stable, appetite good

7
Exam/Eval

• 99.2oF, 139/80, 196 lbs
• Neck with very small (lt 1 cm) cervical nodes, but
  several felt somewhat matted
• Neck and chest biopsy sites well healed
• Hypertrophic scar (? keloid) on right breast at
  biopsy site
• O/W (-)

• Referral data
• CBCs w/diff normal
• CMPs normal
• LFTs normal
• PPD (-) x 2
• CXR (-)
• Biopsy report confirmed

8
Suppurative Granulomatous Lymphadenitis

• Pathologic description of microabscess/PMNs and
  usually loosely formed granulomas within lymph
  node
• Fairly focused DDx
• Cat-scratch disease (Bartonella spp.)
• Leishmaniasis
• Lymphogranuloma venereum (Chlamydia trachomatis)
• Chronic granulomatous disease
• PseudoTB (Corynebacterium ovis)
• Tularemia
• Rarely TB or Aytpical myocbacteria
• ?Unusual reactive node in presence of lymphoid
  malignancy (typically Hodgkins Disease)

9
Pathology
10
A Diagnostic Test Was Performed . . . .

• RPR (-)
• HIV (-)
• Toxoplasma serology (-)
• Bartonella serology (-)
• Leishmania serology (-)
• LGV serology () 1320 IgG, IgM (-)
• Treated initially with Azithromycin x 5 days and
  dramatically better
• Once Dx made, Rx with doxycycline x 21 days
• Issue of the husband . . . .

11
LGV

• 2-10 of genital ulcer disease in Asia/Africa
• Three separate stages of disease after a 3-30 day
  incubation period
• I. Small, painless papule or pustule, heals w/in
  one week
• II. 2-6 weeks later, painful inflammation/lymph
  node swelling most buboes heal without
  complication, but may rupture in 1/3 of patients
• Often have fever, chills, malaise, myalgias
• III. Genitoanorectal syndrome chronic
  inflammatory response, lymphoroids
• Therapy is 21 days of doxycycline 100 mg bid

12
LGV as a cause of cervical lymphadenitis

• Reported in 1976 in JAMA (Thorsteinsson, et al.
  JAMA, 19762351882)
• Pharyngitis and cervical lymphadenopathy
  described as an extragenital infection in 1982
  (Scand J Infect Dis, 198232(S)127-31)
• LGV of the tonsil described in 1990 (J Layngol
  Otol, 1990104331-2)

13
CSD vs. LGV

• Multiple reports of one masquerading as the
  other
• Response to similar therapeutic agents
  (particularly azithromycin) may further confuse
  the situation
• Obviously important to make the proper Dx for
  treatment of partners