Isolated cervical lymph node sarcoidosis presenting in an asymptomatic neck mass: a case report

Synchronous Papillary Thyroid Cancer and Asymptomatic Cervical Lymph Node Sarcoidosis: A Case Report

Sarcoidosis is a systemic inflammatory disease characterized by the formation of immune granulomas in multiple organs. The cause of this disease is not yet clear. Papillary thyroid cancer (PTC) is the most common malignant endocrine tumor and is often associated with cervical lymph node metastasis. Assessment of risk factors associated with a poor prognosis is crucial in PTC. The coexistence of sarcoidosis and thyroid cancer is rarely reported in the literature. We describe a case of a 54-year-old female diagnosed with PTC and asymptomatic cervical and thoracic hilar lymphadenopathy due to concurrent sarcoidosis. This case will remind clinicians to be aware of the multiple potential causes of lymphadenopathy and realize the importance of the differences in the features of neck lymphadenopathy in patients with suspected head and neck cancer. Overall, careful workup and pretreatment screening enabled us to provide the patient with the most suitable treatment modality and avoid total thyroidectomy.

Kikuchi-Fujimoto Disease in a 25-Year-Old Female: A Case Report

BACKGROUND

Kikuchi-Fujimoto disease or histiocytic necrotizing lymphadenitis is a rare benign disease that presents as cervical lymphadenopathy and fever.

CASE PRESENTATION

A 25-year-old South Asian female dentist, recently married, presented to our emergency department due to two weeks of fever, sore throat, swollen neck, and cough. The patient initially presented to a private clinic and was prescribed antibiotics on two visits. On physical examination, her neck was swollen with palpable and tender right posterior and submandibular lymph nodes. Oropharyngeal examination revealed pharyngeal hyperemia without tonsillar enlargement, exudates, or mucocutaneous ulcers. Ultrasound imaging revealed enlarged neck and thoracic and abdominal lymph nodes. CBC showed leukopenia and anemia of chronic disease. B2 microglobulin, lactate dehydrogenase, and kappa light chains were elevated. Anti-ANA, anti-dsDNA, HIV polymerase chain reaction (PCR), Quantiferon-tuberculosis (TB), and rapid plasma reagin were all negative. A lymph node biopsy confirmed the diagnosis of Kikuchi-Fujimoto disease.

CONCLUSION

We believe this is the second case to be reported in the United Arab Emirates (UAE). Kikuchi-Fujimoto disease has a non-specific presentation that overlaps with several conditions including autoimmune, infectious, and malignant. Therefore, a thorough clinical approach and a high grade of clinical suspicion is required to rule out other possible differential diagnosis. Finally, Although Kikuchi-Fujimoto disease is mostly benign, clinicians should be careful as some patients might develop systemic lupus erythematosus (SLE), Still disease, or B cell lymphoma in the future.

Rare Presentations of Sarcoidosis: A Case Series

Sarcoidosis is a systemic disease of unknown etiology with multi-system affection. It typically involves the skin, eyes, hilar lymph nodes, and pulmonary parenchyma. However, as any organ system could be involved, one has to be aware of its atypical manifestations. We present three uncommon manifestations of the disease. Our first case presented with fever, arthralgias, and right hilar lymphadenopathy with a history of tuberculosis in the past. He was treated for tuberculosis but had a relapse of symptoms three months after completion of treatment. The second patient presented with a headache for two months. On evaluation, cerebrospinal fluid examination showed evidence of aseptic meningitis, while an MRI of the brain demonstrated enhancement of the basal meninges. The third patient was admitted with a mass on the left side of the neck for one year. On evaluation, he was found to have left cervical lymphadenopathy, with its biopsy showing non-caseating epitheloid granuloma. Immunofluorescence did not show evidence of leukemia or lymphoma. All the patients had negative tuberculin skin tests and elevated serum angiotensin-converting enzyme levels supporting the diagnosis of sarcoidosis. They were treated with steroids with complete resolution of symptoms and no recurrence at follow-up. Sarcoidosis is an underdiagnosed entity in India. Thus, awareness of the atypical clinical features could lead to early recognition of the disease and its treatment.

Calcified lymph nodes in the setting of head and neck squamous cell carcinoma: A predictor of HPV positivity?

PURPOSE

Human papillomavirus (HPV) is an important cause of head and neck squamous cell carcinoma (HNSCC) and accounts for a large majority of new cases. The purpose of this study is to determine whether there is an association between nodal calcification and HPV positivity in the setting of metastatic HNSCC.

METHODS

Consecutive patients with HNSCC who underwent CT were retrospectively identified. Patients were then divided into two groups: those with HPV-positive HNSCC and those with HPV-negative HNSCC. Demographic, clinical, and CT data were compared between the two groups to determine factors associated with HPV-positive HNSCC.

RESULTS

A total of 179 patients with HNSCC were included in the final analyses, 104 (58%) of whom had HPV-positive tumors. Univariate analyses demonstrated that those with HPV-positive HNSCC were more likely to have calcified lymph nodes (p = 0.044). Analyses also confirmed previously known associations with male gender (p = 0.001), primary oropharyngeal tumors (p < 0.001), and cystic lymph nodes (<0.001). The HPV-positive HNSCC group was also less likely to have necrotic lymph nodes (p < 0.001).

CONCLUSION

In addition to known clinical and imaging factors associated with HPV-positive metastatic HNSCC, such as male gender, oropharyngeal primary location, and cystic lymph nodes, the presence of calcifications within cervical lymph nodes, although infrequent, provides an additional useful feature to predict HPV positivity in HNSCC. Additionally, if calcified lymph nodes are present, then a primary oropharyngeal tumor site should be considered.

Cervical: Lymphadenopathy

The neck region contains around 300 lymph nodes (LNs) out of 800 LNs in the whole body. The detailed study of LNs by Rouviere in 1932 [1] and the later illustration of metastatic predilection of head and neck malignancies to certain LN regions by Lindberg et al. [2] paved the road to a clinically sound classification. The American Academy of Otolaryngology and Head and Neck Surgery (AAO-HNS) and the American Joint Committee on Cancer (AJCC) developed the currently widely accepted levels classification of the cervical LNs (Table 8.1, Figs. 8.1 and 8.2).