Bilateral Hilar and Mediastinal Lymphadenopathy as an Initial Manifestation of Amyloidosis

A 75-year-old male visited our hospital with bilateral hilar lymph node swelling detected on chest radiography during an annual medical checkup. Chest computed tomography revealed swelling of multiple hilar mediastinal lymph nodes. Histopathological and immunohistochemical examinations of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) specimens from the hilar lymph nodes revealed amyloid deposition. Bilateral hilar and mediastinal lymphadenopathies can be the first manifestations of amyloidosis diagnosed using EBUS-TBNA.

Bartonella henselae Infection and Lymphadenopathy in a Patient With T Cell Acute Lymphoblastic Leukemia

Patients undergoing therapy for T cell acute lymphoblastic leukemia are at risk of infections during their treatment course. Cat scratch disease caused by Bartonella hensalae can masquerade as leukemic relapse and cause systemic infection. Obtaining a thorough exposure history may aid clinicians in making the diagnosis.

Incidental lymphadenopathy in renal transplantation

INTRODUCTION

Iliac lymphadenectomy is performed to provide anastomotic access during the vascular implantation procedure in renal transplantation. Iliac lymph nodes (LNs) are often enlarged, but there are no standardised guidelines for the management of incidentally enlarged LNs during transplantation. We aimed to evaluate histological findings of LNs sent for examination at our unit.

METHODS

Patients were evaluated in two distinct date cycles. In the first cycle, lymphadenectomy and histological assessment were performed at the discretion of the transplanting surgeon. In the second cycle, all incidentally enlarged LNs were sent for histological assessment, regardless of size.

RESULTS

In the first cycle (n = 76), 11 patients (14.47%) had incidentally enlarged iliac LNs on lymphadenectomy and histology showed only reactive changes. In the second cycle (n = 165), eight patients (4.85%) had incidentally enlarged LNs on lymphadenectomy. One patient was found to have mature B cell chronic lymphocytic leukaemia. The patient was referred to haematology and a "watch and wait" approach was taken, with the patient still alive at last follow-up (511 days post-transplantation).

DISCUSSION

There are currently no published guidelines on the management of incidentally enlarged iliac LNs during transplantation. Current literature suggests that clinically significant lymphadenopathy needs to be investigated in all patients. Based on our centre's experience of a 5.26% (1 in 19) positive pathological LN sampling, we recommend that all incidental LNs with suspicious features and/or that are greater than 10mm in diameter should be considered for histological, microbiological and molecular assessment as appropriate.

Comparison of Axillary Lymph Nodes on Breast MRI Before and After COVID-19 Booster Vaccination

RATIONALE AND OBJECTIVES

Vaccine-related lymphadenopathy is a frequent finding following initial coronavirus disease 2019 (COVID-19) vaccination, but the frequency after COVID-19 booster vaccination is still unknown. In this study we compare axillary lymph node morphology on breast MRI before and after COVID-19 booster vaccination.

MATERIALS AND METHODS

This retrospective, single-center, IRB-approved study included patients who underwent breast MRI between October 2021 and December 2021 after the COVID-19 booster vaccination. The axillary lymph node with the greatest cortical thickness ipsilateral to the side of vaccination was measured on MRI after booster vaccination and before initial COVID-19 vaccination. Comparisons were made between patients with and without increase in cortical thickness of ≥ 0.2 cm. Continuous covariates were compared using Wilcoxon rank-sum test and categorical covariates were compared using Fisher's exact test. Multiple comparison adjustment was made using the Benjamini-Hochberg procedure.

RESULTS

All 128 patients were included. Twenty-four of 128 (19%) displayed an increase in lymph node cortical thickness of ≥ 0.2 cm. Patients who received the booster more recently were more likely to present cortical thickening, with a median of 9 days (IQR 5, 20) vs. 36 days (IQR 18, 59) (p < 0.001). Age (p = 0.5) and type of vaccine (p = 0.7) were not associated with thickening. No ipsilateral breast cancer or malignant lymphadenopathy were diagnosed on follow-up.

CONCLUSION

Axillary lymphadenopathy on breast MRI following COVID-19 booster vaccination is a frequent finding, especially in the first 3 weeks after vaccination. Additional evaluation or follow-up may be omitted in patients with low concern for malignancy.

Case of IgG4-related Disease with Crescentic Glomerulonephritis: An Unusual Presentation of the Disease

IgG4-related disease (IgG4-RD) is a chronic systemic inflammatory  disease, characterized by tissue infiltration of lymphocytes and  IgG4-secreting plasma cells, presenting by fibrosis of different  tissues, which is usually responsive only to oral steroids therapy.  Kidneys are the most commonly involved organs, exhibiting renal  insufficiency, tubulointerstitial nephritis, and glomerulonephritis.  Here, we describe a patient with acute renal insufficiency who  was presented with edema, weakness, anemia and multiple  lymphadenopathies. Kidney and lymph node biopsy showed  crescentic glomerulonephritis in kidneys and lymphoplasmacytic  infiltration in lymph nodes. After a course of treatment with an  intravenous pulse of corticosteroid and cyclophosphamide, the  patient's symptoms subsided, and kidney function improved. DOI: 10.52547/ijkd.7788.

Leukemic pulmonary infiltrates in chronic lymphocytic leukemia: Clinical and imaging features

BACKGROUND

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in Western countries. Although various patterns of lung involvement with CLL have been reported, data on clinicoradiologic presentation are sparse.

METHODS

A computer-assisted search was conducted to identify patients encountered at Mayo Clinic from 1998 to 2022 and had leukemic pulmonary infiltrates (LPI) with CLL demonstrated on lung biopsy. Medical records and chest imaging studies were reviewed to identify clinical and radiologic features.

RESULTS

Among 13 patients, median age was 77 years (range: 60-88) and included 10 men (77 %). All patients were known to have CLL with a median duration of 96 months (range: 50-408), and none were on treatment. Most common symptoms were dyspnea (62 %), cough (54 %), and fatigue (46 %); 2 patients (15 %) were asymptomatic. Dominant abnormality on CT consisted of single or multiple nodular/mass-like opacities in 10 patients (77 %), while diffuse centrilobular nodules, pleural mass, and diffuse bronchial wall thickening were each seen in one patient, respectively; intrathoracic lymphadenopathy was present in all. After diagnosis of LPI, treatment for CLL was administered to 7 patients (54 %); 6 patients (86 %) exhibited improvement. During follow-up (median 41 months), 8 (62 %) patients died. Causes of death included progressive CLL or treatment-related complications (2 patients), pneumonia (1 patient), unrelated causes (3 patients), and unknown in 2 patients.

CONCLUSIONS

LPI in CLL is generally encountered in patients with known untreated CLL. The main imaging feature is single mass-like opacity or multiple nodular/mass-like opacities, associated with intrathoracic lymphadenopathy.

[Intranodal palisaded myofibroblastome: A rare cause of inguinal lymphadenopathy]

INTRODUCTION

Lymphadenopathies are a major cause of consultation in internal medicine, with various causes of diagnosis. Unexplained persistent lymphadenopathy must be biopsied to rule out malignant tumor.

CASE REPORT

We report the case of a 53-year-old man, with inguinal lymphadenopathy evolving for more than one year. The patient had no associated symptoms and his blood tests were unremarkable. Due to the progression of the adenopathy and its hypermetabolism on PET-CT, an excisional biopsy was performed. Histological analysis revealed an intranodal proliferation of spindle cells with a palisading pattern. β-catenine and smooth muscle actin labelling were positive, leading to the diagnosis of intranodal palisaded myofibroblastoma, a benign tumour.

CONCLUSION

Intranodal palisaded myofibroblastoma is a rare benign cause of adenopathy, with often inguinal lymph node localization and slow growth and without risk of recurrence after surgical removal.

Hypermetabolic Axillary Lymphadenopathy After Shingrix Vaccination for Varicella Zoster Virus

ABSTRACT

A 67-year-old woman underwent staging 18 F-FDG PET/CT scan for recently diagnosed breast cancer. Her scan showed a highly hypermetabolic right breast mass, with ipsilateral hypermetabolic axillary lymph nodes. The contralateral axillary lymph nodes were also enlarged with avid FDG uptake, alongside focal increased uptake in the left deltoid muscle. Upon investigation, the patient reported receiving the new zoster recombinant adjuvanted varicella zoster vaccine (Shingrix, GlaxoSmithKline) 4 days before the scan. The lymph node uptake could be potential pitfall for cancer staging.

Prevalence, clinical characteristics, and management of silicone lymphadenopathy: A systematic review of the literature

INTRODUCTION

Implant-based breast augmentations and reconstructions are one of the most common surgical procedures performed by plastic surgeons in the United States, which has rapidly increased in popularity since the 2000s. Silicone lymphadenopathy (SL) is a complication of breast implants that involves migration of silicone to nearby soft tissue/lymph nodes. Data on its clinical features and management is scarce.

METHODS

SL-related search terms were used to find articles in 3 databases. Of 598 articles, 101 studies met the inclusion criteria. Demographics, clinical presentation, workup, and management data were analyzed.

RESULTS

Of 279 cases of SL and 107 with information on initial diagnosis, 35 (33%) were incidental. The most common symptom was painless lymphadenopathy, followed by painful lymphadenopathy. 251 (95%) and 13 (5%) patients had silicone and saline implants, respectively. 149 (68%) patients had implant rupture. Axillary lymphadenopathy was the most affected region (136 cases, 72%), followed by internal mammary (40 cases, 21%), cervical/supraclavicular (36 cases, 19%), and mediastinal (24 cases, 13%) regions. 25% of patients underwent fine-needle aspiration, 12% core needle biopsy, and 59% excisional biopsy. 32% of cases underwent explantation and/or implant exchange. The most common indication for surgery was implant rupture. Histology showed multinucleated giant cells, large histiocytes, and silicone accumulation.

CONCLUSIONS

SL is a complication associated with breast implants. The majority of patients are asymptomatic, and most cases are managed conservatively. Minority need a biopsy and surgical interventions due to abnormal imaging, persistent symptoms, and/or implant rupture. Workup and management should be tailored to the patient.

Cytokine storm syndrome after anti-thymoglobulin infusion in a cynomolgus monkey with systemic lymphadenopathy caused by follicular hyperplasia: A case report

Nonhuman primates are widely used in transplantation research as preclinical xeno- or allo-transplantation models. Rabbit anti-thymoglobulin (ATG) is often used for T-cell depletion as an immunosuppressant. T-cell depletion can cause a secondary cytokine storm syndrome that can be minimized/prevented by a prophylactic administration of systemic corticosteroids and antihistamines. We report a case of death due to CSS in a cynomolgus monkey with follicular hyperplasia-induced systemic lymphadenopathy after ATG administration. A 6-year-old female cynomolgus monkey was rendered diabetic and then transplanted with a genetically modified porcine pancreatic islets (PPI) (50 000 IEQ/kg) through the portal vein 22 days later without immunosuppressant. Because graft function was not comparable, we planned re-transplantation of PPI. For re-transplantation of the PPI, we performed an intravenous (IV) ATG infusion for inductive immunosuppression. The monkey died 3 h and 30 min after ATG administration despite cardiopulmonary resuscitation. Systemic lymphadenopathy was observed on submandibular, axillary, inguinal, foregut, colic, and hilar lymph nodes, and splenomegaly was also observed on necropsy. Histopathologic examination of the lymph node revealed follicular hyperplasia. The IL-6 level was higher after ATG infusion compared to before ATG infusion (before vs. after ATG infusion; 14.9 vs. >5000 pg/mL). The death of the cynomolgus monkey was caused by severe CSS because of apoptosis of B cells in the systemic lymph nodes caused by the ATG administration. A thorough physical examination of palpable lymph nodes and pre-ATG sonographic or computed tomographic screening could have identified lymphadenopathy, potentially preventing its infusion and reducing mortality risk.

[Epstein-Barr virus-associated gastritis with perigastric lymphadenopathy accompanied by infectious mononucleosis:a case report]

A 28-year-old female patient with no particular medical history had a sore throat seven days before admission. Subsequently, she developed malaise, right abdominal pain, and a fever of 38°C and visited our hospital. A blood test revealed a mild inflammatory response and elevated liver enzymes, and she was admitted to the hospital for detailed examination and acute liver injury treatment. Various viral tests and autoantibody measurements revealed elevated Epstein-Barr virus (EBV) immunoglobulin M and negative EB nuclear antigen antibodies. Therefore, she was diagnosed with primary infectious mononucleosis-associated EB viral hepatitis. Abdominal computed tomography upon admission revealed swollen lymph nodes around the stomach;thus, esophagogastroduodenoscopy (EGD) was performed. A histopathological examination revealed severe lymphocytic infiltration, and EB encoding region in situ hybridization demonstrated that 10-20% of the lymphocytes were EBV-infected. Drip and rest treatment improved the patient's liver enzymes, and her symptoms resolved. Repeat EGD after two months revealed improved gastric erosions. Here, we report a case of EBV-associated gastritis that was discovered due to perigastric lymphadenopathy accompanied by infectious mononucleosis. This report includes a review of the literature because a few studies reported EBV-associated gastritis.

Tender Cervical Lymphadenopathy in a Pediatric Patient

An 11-year-old boy presented with enlarged and tender cervical lymph nodes that showed areas of central hypodensity and necrosis with histiocytes and an absence of neutrophils. What is your diagnosis?

False-Positive Nodes With Axillary Silicone Lymphadenopathy in an Oncologic Patient With a Rare Breast Cancer and Implant Rupture

In this case, a 43-year-old woman with a rare breast tumor and a history of augmentation mammoplasty is presented. The patient arrived at the clinic reporting a palpable lump in the right mammary gland and two ipsilateral axillary nodes with pain on palpation. Mammography and ultrasound confirmed the presence of a 4 cm tumor and 2 metastatic lymph nodes of 2 cm each, histopathological diagnosis was an encapsulated papillary cancer and two siliconomas, respectively. Interestingly, these nodes were able to take up technetium 99 and methylene blue contrast media. Due to these findings, adequate patient management was carried out with a skin-sparing mastectomy and hormonal treatment with tamoxifen. This report is relevant as it shows that axillary lymphadenopathy caused by silicone must be considered in the evaluation of a patient with a cancer diagnosis and history of augmentation mammoplasty, especially breast cancer as the node siliconomas present a high risk of being considered a false positive metastasis.

Comparison of post-COVID-19 vaccination hypermetabolic lymphadenopathy on 18F-fluorodeoxyglucose PET/CT between virus-vector vaccine and mRNA vaccine

PURPOSE

We compared hypermetabolic lymphadenopathy (HLN) on 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) after virus-vector and mRNA vaccines for coronavirus disease 2019 (COVID-19).

METHODS

This retrospective study included 573 participants who underwent FDG PET/CT after receiving a virus-vector vaccine (ChAdOx1, AstraZeneca [AZ] group) or an mRNA vaccine (mRNA-1273, Moderna [M] group) from July 2021 to October 2021. The incidence and avidity of HLN were evaluated and correlated with clinical features and vaccine type. The final analysis was conducted with 263 participants in the AZ group and 310 participants in the M group.

RESULTS

The HLN incidence was significantly lower in the AZ group than in the M group (38/263 [14%] vs. 74/310 [24%], p = 0.006). The FDG avidity of HLN was comparable between the two groups. The HLN incidence in both groups was significantly higher within 4 weeks after the vaccination compared with more than 4 weeks. The HLN incidence within 4 weeks of the vaccination was significantly higher in the M group than in the AZ group (p = 0.008), whereas a difference in HLN incidence between the two groups was not observed after the same duration (p = 0.11).

CONCLUSIONS

The mRNA mRNA-1273 COVID-19 vaccine was found to be associated with higher glucose hypermetabolism in regional lymph nodes within the first 4 weeks compared with the virus-vector vaccine, as indicated by the presence of HLN on FDG PET/CT. The degree of glucose hypermetabolism was comparable between the two vaccines.

Case Report: Gene expression profiling of COVID-19 vaccination-related lymphadenopathies reveals evidence of a dominantly extrafollicular immune response

mRNA-based vaccines against SARS-CoV-2 have been proven to be very efficient in preventing severe COVID-19. Temporary lymphadenopathy (LA) has been observed as a common adverse event following immunization. Here we describe a case series of three female patients with prominent local to generalized LA after SARS-CoV-2 mRNA-1273 vaccination, which led to lymph node biopsy due to the suspicion of lymphoma or metastasis. All three patients morphologically showed similar patterns of follicular hyperplasia and especially extrafollicular blast activation. Two of the three patients only had short-lasting humoral immune responses to the vaccination. Gene expression profiling (GEP) using the HTG Immune response panel revealed that all three patients clustered together and clearly differed from the GEP-patterns of COVID-19, infectious mononucleosis and non-specific follicular hyperplasia. The closest similarities were seen with lymph nodes showing extrafollicular activation of B-blasts as well as hemophagocytosis. The GEP of the vaccination-induced LA was reminiscent of an immune response with little potential of immunologic memory. mRNA-1273 vaccination-induced LA may to a certain extend reflect disordered immune response with potentially poor immunologic memory in affected individuals.

The co-occurrence of Kikuchi-Fujimoto disease and systemic lupus erythematosus: a case report

BACKGROUND

Kikuchi-Fujimoto disease is an uncommon systemic disease that mostly affects young women. Kikuchi-Fujimoto disease typically manifests as necrotizing lymphadenopathy, which frequently follows by a fever; however, Kikuchi-Fujimoto disease occurs rarely in extranodal regions. One of the most important accompaniments of Kikuchi-Fujimoto disease is its connection with autoimmune diseases such as systemic lupus erythematosus. This case presents a simultaneous occurrence of Kikuchi-Fujimoto disease with liver involvement and systemic lupus erythematosus in a young female patient.

CASE PRESENTATION

We present a rare case of a 20-year-old white woman who presented with fever, joint pains, myalgia, and shortness of breath. Initial hospitalization and treatment for fever of unknown origin did not yield improvement. Physical examination revealed cervical and supraclavicular lymphadenopathy, and laboratory investigations showed abnormal blood counts, elevated inflammatory markers, and positive autoimmune serologies. Imaging studies revealed bilateral pleural effusion and liver lesions. Lymph node biopsy confirmed the diagnosis of Kikuchi-Fujimoto disease, and liver biopsy showed extranodal involvement. The patient was diagnosed with Kikuchi-Fujimoto disease-associated systemic lupus erythematosus and treated with hydroxychloroquine and corticosteroids. The patient showed gradual resolution of symptoms and lymphadenopathy with treatment.

CONCLUSION

Kikuchi-Fujimoto disease is a rare systemic condition primarily impacting young females. It is characterized by necrotizing lymphadenopathy, often accompanied by fever. Although Kikuchi-Fujimoto disease is predominantly seen in the lymph nodes, occurrences in non-nodal areas are infrequent. When diagnosing Kikuchi-Fujimoto disease, it is essential to screen patients for systemic lupus erythematosus. In this particular case, we observed liver involvement along with the presence of both Kikuchi-Fujimoto disease and systemic lupus erythematosus.

The Diagnostic Yield of Excisional Biopsy in Cervical Lymphadenopathy: A Retrospective Analysis of 158 Biopsies in Adults

OBJECTIVES

Cervical lymph nodes are the most common site of peripheral lymphadenopathy. The underlying etiologies are usually benign and self-limiting but may include malignancies or other severe life-threatening diseases. The aim of the current study was to investigate the various underlying pathologies of cervical lymphadenopathy as assessed by the diagnostic yield of excisional lymph node biopsies of the neck in a tertiary adult practice. The evaluation was performed in light of previous literature and regional epidemiological patterns.

METHODS

Retrospective analysis of hospital charts of 158 adult patients who underwent an excisional biopsy for suspected cervical lymphadenopathy at a tertiary referral head and neck service between January 2017 and December 2019.

RESULTS

The most common underlying pathology was unspecific and/or reactive lymphadenitis in 44.5% of specimens, followed by malignant disease in 38.6% of cases. An age above 40 years was significantly correlated with an increased likelihood of malignant disease. Lower jugular and posterior triangle lymph nodes showed higher malignancy rates than other groups (100% and 66.7%, respectively). The overall surgical complication rate was 2.5%.

CONCLUSIONS

The results of the current study serve as an indicator of the variety of etiologies causing cervical lymphadenopathy. In particular, given the increasing incidence of malignant diseases in recent decades, the findings should alert physicians to the importance of lymph node biopsy for excluding malignancy in persistent cervical lymphadenopathy especially in older adults. The findings emphasize the value of excisional lymph node biopsy of the neck as a useful diagnostic tool in adult patients with peripheral lymphadenopathy.

Breast-implant Related Silicone Lymphadenopathy: Asteroid Bodies do not Always Equal Sarcoidosis!

Silicone breast implants are frequently used for breast augmentation for cosmetic purposes, as well as for breast reconstruction after prophylactic or therapeutic mastectomy. Silicone lymphadenopathy is a well-known complication of silicone breast implants. Silicone droplets are present in the breast tissue through 'silicone bleeding' of the implant or because of implant rupture. These silicone particles can migrate from the breast to the regional lymph nodes. Silicone lymphadenopathy is caused by a substantial foreign body reaction against these silicone particles, and is frequently associated with asteroid body-containing multinucleated giant cells. Similar multinucleated giant cells are often observed in the capsule surrounding the silicone breast implant, and the number of associated asteroid bodies is highly variable. Here, we discuss a series of twelve women with breast implant-related asteroid bodies in their lymph nodes and/or breast tissue. This pictorial essay illustrates that the presence of asteroid bodies in a lymph node does not necessarily suggests a diagnosis of sarcoidosis. Clinical information about the patient having (or having had) silicone breast implants is often lacking. The encounter of asteroid body-containing giant cells in lymph node cytology, biopsies or resections should therefore lead to reflex clinical-pathological correlation, before establishing a final diagnosis.

Differential diagnosis of lymphoma with 18F-FDG PET/CT in patients with fever of unknown origin accompanied by lymphadenopathy

PURPOSE

To investigate the value of 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) in the differential diagnosis of lymphoma in patients with fever of unknown origin (FUO) accompanied by lymphadenopathy and to develop a simple scoring system to distinguish lymphoma from other etiologies.

METHODS

A prospective study was conducted on patients with classic FUO accompanied by lymphadenopathy. After standard diagnostic procedures, including PET/CT scan and lymph-node biopsy, 163 patients were enrolled and divided into lymphoma and benign groups according to the etiology. The diagnostic utility of PET/CT imaging was evaluated, and beneficial parameters that could improve diagnostic effectiveness were identified.

RESULTS

The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET/CT in diagnosing lymphoma in patients with FUO accompanied by lymphadenopathy were 81.0, 47.6, 59.3, and 72.7%, respectively. The lymphoma prediction model combining high SUVmax of the "hottest" lesion, high SUVmax of the retroperitoneal lymph nodes, old age, low platelet count, and low ESR had an area under the curve of 0.93 (0.89-0.97), a sensitivity of 84.8%, a specificity of 92.9%, a PPV of 91.8%, and an NPV of 86.7%. There was a lower probability of lymphoma for patients with a score < 4 points.

CONCLUSIONS

PET/CT scans show moderate sensitivity and low specificity in diagnosing lymphoma in patients with FUO accompanied by lymphadenopathy. The scoring system based on PET/CT and clinical parameters performs well in differentiating lymphoma and benign causes and can be used as a reliable noninvasive tool.

REGISTRATION NUMBER

This study on FUO was registered on http://www.

CLINICALTRIALS

gov on January 14, 2014, with registration number NCT02035670.

A 40-Year-Old Man With Multiple Pulmonary Nodules and Mediastinal Lymphadenopathy With Positive Anti-Neutrophil Cytoplasmic Antibody Reveals an Unexpected Diagnosis

CASE PRESENTATION

A 40-year-old man with no significant medical history presented to the ED with a 2-day history of right-sided chest pain accompanied by night sweats and chills. These symptoms were accompanied by a dry, nonproductive cough without hemoptysis. The patient worked as an air traffic controller, with a side business of buying, renovating, and selling houses. He takes part in the remodeling work himself but denies any exposure to animal droppings, bird droppings, or mold. He denied chronic sinus disease, rash, or arthralgias. A resident of Platte City, Missouri, he had recently traveled to Salt Lake City, Utah. At the time of presentation, the patient denied any fever or shortness of breath. He had no history of nicotine, alcohol, or illicit substance use and denied any recent weight loss.

Detection of axillary lymphadenopathy after Covid-19 vaccination during breast examination: Case series and review of the literature after one year

OBJECTIVES

The aim of this study is to evaluate accidental findings of axillary lymphadenopathy during breast examination. Postvaccination axillary lymphadenopathy is a possible cause of adenopathies but these findings used to be exceedingly rare. Nowadays, after Covid-19 vaccination it is found more often. Covid-19 vaccination started at the end of December 2020 with two types of vaccine, Moderna and Pfizer-BioNTech in the Czech Republic. The aim of this article is to present a single centre experience with Covid-19 lymphadenopathy during the general vaccination in the Czech population and summarization of recommendations.

METHODS

In January to February 2021 ultrasound revealed axillary lymphadenopathy in several patients during breast examination in our certified centre. In four of them it was concluded as lymphadenopathy after Covid-19 vaccination. A search (using databases PubMed and Google Scholar) of the available literature for the years 2020 and 2021 was performed.

RESULTS

These four patients were examined during the first two months of 2021. In all of them pathological lymph nodes with typical sonographic signs were seen in the ipsilateral axilla. We searched the literature for follow-up recommendations and summarized them in our article.

CONCLUSION

Accidental findings of axillary lymphadenopathy during ultrasound breast examination will be more often. There will be more cases of lymphadenopathy with an increasing number of people being vaccinated against Covid-19.

Surgery in Early Metastatic Seminoma: A Phase II Trial of Retroperitoneal Lymph Node Dissection for Testicular Seminoma With Limited Retroperitoneal Lymphadenopathy

PURPOSE

The long-term toxicities of chemotherapy and radiotherapy can represent a significant burden to testicular cancer survivors. Retroperitoneal lymph node dissection (RPLND) is an established treatment for testicular germ cell tumors with minimal late morbidity although little data exist on its efficacy in early metastatic seminoma. Surgery in early metastatic seminoma is a prospective phase II single-arm, multi-institutional trial of RPLND as first-line treatment for testicular seminoma with clinically low-volume retroperitoneal lymphadenopathy.

PATIENTS AND METHODS

Twelve sites in the United States and Canada prospectively enrolled adult patients with testicular seminoma and isolated retroperitoneal lymphadenopathy (1-3 cm). Open RPLND was performed by certified surgeons with a primary end point of 2-year recurrence-free survival (RFS). Complication rates, pathologic up/downstaging, recurrence patterns, adjuvant therapies, and treatment-free survival were assessed.

RESULTS

A total of 55 patients were enrolled, with a median (IQR) largest clinical lymph node size of 1.6 cm (1.3-1.9). RPLND pathology demonstrated a median (IQR) largest lymph node size of 2.3 cm (0.9-3.5); nine patients (16%) were pN0, 12 (22%) pN1, 31 (56%) pN2, and 3 (5%) pN3. One patient received adjuvant chemotherapy. With a median (IQR) follow-up of 33 months (12.0-61.6), 12 patients experienced recurrence, with a 2-year RFS of 81% and a recurrence rate of 22%. Of the patients who experienced recurrence, 10 were treated with chemotherapy and two underwent additional surgery. At last follow-up, all patients who experienced a recurrence were disease-free and the 2-year overall survival was 100%. Four patients (7%) experienced short-term complications, and four patients experienced long-term complications including incisional hernia (1) and anejaculation (3).

CONCLUSION

RPLND is a treatment option for testicular seminoma with clinically low-volume retroperitoneal lymphadenopathy and is associated with low long-term morbidity.

Bilateral Lymphadenopathy After COVID Vaccine in 18F-Choline PET/MRI Performed for Hyperparathyroidism

ABSTRACT

We describe a case of a 56-year-old woman with primary hyperparathyroidism. 18F-Choline PET/MRI revealed incidental bilateral axillary lymphadenopathy with mild-moderate increased 18F-choline uptake. The patient had her first and third doses of COVID-19 vaccines from the left arm and second dose of vaccine from the right arm before PET examination.

Differences in the Clinical Characteristics of Kawasaki Disease Between Older and Younger Children (2015-2019): A Single-Center, Retrospective Study

OBJECTIVE

The objective of this study was to investigate the differences in the clinical characteristics of Kawasaki disease between older and younger children.

STUDY DESIGN

This retrospective study examined 405 children with Kawasaki disease admitted to Showa University Northern Yokohama Hospital between 2015 and 2019.

RESULTS

Eligible patients were classified into the older (≥3.0 years of age, n = 169) and younger (<3.0 years of age, n = 236) groups. Skin rash was found in significantly fewer cases (112 [66.3%] vs 229 [97.0%], P < .001 in the younger group). Cervical lymphadenopathy was more common in older children (153 [90.5%] vs 165 [69.9%], P < .001) and in incomplete Kawasaki disease (3 or 4 findings) (34 [20.1%] vs 25 [10.6%], P = .0078). The diagnosis was more delayed in older children (median: 5.0 days vs 4.0 days, P = .003) than the younger group. Additionally, fever nonresponsive to a single intravenous immunoglobulin was more common, and the duration of fever was significantly longer in the older group (48 [28.4%] vs 47 [19.9%], P = .0479).

CONCLUSIONS

Kawasaki disease should be suspected in children aged >3.0 years with cervical lymphadenopathy and fever, despite the absence of skin rash. Additionally, incomplete Kawasaki disease, fever unresolved by a single intravenous immunoglobulin infusion, and the tendency to delay treatment initiation are more common in children aged >3.0 years.

Development of IgG4-related pancreatitis and kidney disease 7 years after the onset of undiagnosed lymphadenopathy: A case report

This report describes a patient diagnosed with immunoglobulin G4 (IgG4)-related pancreatitis and kidney disease 7 years after the onset of undiagnosed lymphadenopathy. A 48-year-old Japanese woman presented with fatigue and leg oedema. Computed tomography showed perigastric lymphadenopathy, for which she underwent a laparoscopic biopsy of the perigastric lymph nodes. Although histopathological examination of the lymph nodes did not lead to a definitive diagnosis, serological tests revealed elevated serum IgG4 levels (558 mg/dl) and IgG4 immunostaining of the lymph nodes showed IgG4-positive plasma cell infiltration, leading to the suspicion of IgG4-related disease. Further workup revealed no organ lesion other than lymphadenopathy. At age 55 years, despite having no subjective symptoms, contrast-enhanced computed tomography showed low-density lesions in the tail of the pancreas and the left kidney. Histopathological examination showed lymphocyte infiltration, consisting of a mixture of plasma cells and eosinophils, in both organs and obliterative phlebitis in the pancreas. IgG4 immunostaining of the kidney specimens showed 160 IgG4-positive cells per high-powered field, with the IgG4+/IgG+ cell ratio being almost 100%, leading to a diagnosis of IgG4-related pancreatitis and kidney disease. Treatment with prednisolone for 2 months resulted in lesion improvement. Although the diagnosis of IgG4-related lymphadenopathy is often challenging in patients with lymphadenopathy alone, findings in the present patient emphasise the importance of long-term follow-up, as it may allow early detection of involvement of other organs by IgG4-related disease.

Kikuchi-Fujimoto disease following SARS-CoV-2 vaccination

A previously healthy Japanese woman in her 20s was admitted to our hospital with a 2-week history of fever (39.0°C) and a 1-week history of painful cervical lymphadenopathy. The day before fever onset, she had received her first Pfizer-BioNTech SARS-CoV-2 vaccine in her left arm. She had previously been treated with empirical antibiotics with no improvement. Physical examination revealed painful lymphadenopathy in both posterior cervical regions. CT showed symmetrical lymphadenopathies in the neck, supraclavicular, axillary and inguinal regions as well as hepatosplenomegaly. We suspected lymphoma and performed a lymph node biopsy in the right inguinal region, which revealed necrotising histiocytic lymphadenitis. The patient was, therefore, diagnosed with Kikuchi-Fujimoto disease (KFD). She improved after the corticosteroid therapy. This report highlights the importance of including KFD as a differential diagnosis of lymphadenopathy after SARS-CoV-2 vaccination. Additionally, lymph node biopsy is helpful for diagnosing KFD because it rules out other entities.

COVID-19 Vaccine-Associated Lymphadenopathy Mimicking Regrowth of Axillary Lymph Node Metastasis of Lung Adenocarcinoma

We encountered a woman with re-enlarged axillary lymph nodes during a computed tomography (CT) scan for surveillance of lung adenocarcinoma with axillary lymph node metastasis at the initial diagnosis that had shrunk with standard chemotherapy. We first suspected cancer recurrence and considered a change in the chemotherapeutic regimen. However, after careful history taking regarding the timing of her Coronavirus Disease 2019 (COVID-19) vaccination, and subsequent careful, close follow-up, radiological shrinkage suggested a strictly benign cause. Especially in lung cancer with a medical history of axillary lymph node involvement, cliniciansshould be aware that vaccine-associated lymphadenopathy can mimic cancer recurrence and sometimesprompt serious misjudgment regarding a current treatment course and strategy.

US Evaluation of Axillary Lymphadenopathy Following COVID-19 Vaccination: A Prospective Longitudinal Study

Background Both temporal changes in imaging characteristics of lymphadenopathy on US scans after COVID-19 vaccination and expected duration of radiologically evident lymphadenopathy remain uncertain. Purpose To longitudinally evaluate COVID-19 vaccine-associated lymphadenopathy on axillary US scans at various time intervals in both messenger (mRNA) and vector vaccine recipients. Materials and Methods This prospective cohort study was conducted between March 2021 and January 2022. The participants were asymptomatic women without breast cancer who had received COVID-19 vaccination. Serial follow-up US was performed in women with lymphadenopathy. The following variables were assessed: cortical thickness, number of lymph nodes, morphologic characteristics, and Doppler signal. Temporal changes in cortical thickness and number of lymph nodes during follow-up were assessed using a linear mixed model. Results Ninety-one women with lymphadenopathy in the vaccinated arm had undergone a total of 215 serial US examinations (mean age, 44 years ± 13 [SD]). Fifty-one participants had received a vector vaccine (ChAdOx1 nCoV-19 vaccine) and 40 had received an mRNA vaccine (BNT162b2 vaccine [n = 37] and mRNA-1273 vaccine [n = 3]). Three of the 91 women were lost to follow-up; thus, 88 women underwent serial US. Complete resolution of axillary lymphadenopathy was observed at a median of 6 weeks after vaccination (range, 4-7 weeks) in 26% of women (23 of 88). Among 49 women with follow-up US at a median of 12 weeks after vaccination (range, 8-14 weeks), persistent lymphadenopathy was observed in 25 (51%). During the follow-up period, the cortical thickness gradually decreased (P < .001) over time regardless of vaccine type; however, values were higher in recipients of the mRNA vaccine than in recipients of the vector vaccine (P = .02). Conclusion COVID-19 vaccine-associated axillary lymphadenopathy frequently persisted for more than 6 weeks on US scans. Lymphadenopathy should be interpreted considering vaccine type and time elapsed since vaccination. Follow-up US examination at least 12 weeks after vaccination may be reasonable, particularly for recipients of the messenger RNA vaccine. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Moy and Kim in this issue.

COVID-19 vaccine associated cervical lymphadenopathy: a case series

BACKGROUND

COVID-19 is an evolving worldwide pandemic causing significant morbidity and mortality. COVID-19 vaccinations have been developed to increase immunity against the virus. In New Zealand, the Pfizer BioNTech mRNA vaccine has been provisionally approved for use. Axillary lymphadenopathy is a recognized side effect of the mRNA vaccine, however cervical lymphadenopathy has also been reported. Due to a wide range of differential diagnoses, the finding of cervical lymphadenopathy requires thorough investigation which can include imaging and invasive diagnostic procedures.

METHODS

Five patients were identified by otorhinolaryngology (ORL) consultants at Whangarei Base Hospital and Waikato Hospital between 15/7/2021 and 21/12/2021 after being investigated through high suspicion of cancer triage pathways set by the New Zealand Ministry of Health. Inclusion criteria were adult patients with cervical lymphadenopathy following vaccination. Exclusion criteria were no history of vaccination or lymphadenopathy present before vaccination.

RESULTS

All patients were identified to have cervical lymphadenopathy on radiological imaging and a recent history of COVID-19 vaccination with the Pfizer BioNTech vaccine. Interval vaccination to fine needle aspiration time ranged between 41 and 76 days. All patients had cytological or histological diagnosis showing reactive findings or interval imaging showing resolution of lymphadenopathy.

CONCLUSION

With increasing levels of COVID-19 vaccination and booster vaccinations we will continue to see cases of COVID-19 vaccine associated cervical lymphadenopathy. We highlight the importance of taking a COVID-19 vaccination history and including COVID-19 associated cervical lymphadenopathy in the differential diagnosis of presentation with a neck lump.

Two Cases of Kikuchi Disease Presenting with Aseptic Meningitis and Encephalitis

Kikuchi disease, also called histiocytic necrotizing lymphadenitis, is an idiopathic and generally self-limiting disease affecting young adults and children. Kikuchi disease does not commonly manifest neurological complications at its initial presentation. We herein report two cases of Kikuchi disease that initially presented with aseptic meningitis and encephalitis rather than the more common signs of lymphadenopathy, rash, and arthritis. A 15-year-old boy presented with aseptic meningitis with an extremely high intracranial pressure. A 28-year-old man presented with dysesthesia of the right lower extremity, coinciding with abnormal magnetic resonance imaging findings. In both cases, painful cervical lymphadenopathy was observed following the central nervous system symptoms. Both patients improved after treatment with steroids. Kikuchi disease occasionally affects the central nervous system, to which lymphadenitis may be observed subsequently. A repeated, careful physical examination of the cervical lymph nodes may be helpful for the diagnosis.

FDG PET/CT radiomics as a tool to differentiate between reactive axillary lymphadenopathy following COVID-19 vaccination and metastatic breast cancer axillary lymphadenopathy: a pilot study

OBJECTIVES

To evaluate if radiomics with machine learning can differentiate between F-18-fluorodeoxyglucose (FDG)-avid breast cancer metastatic lymphadenopathy and FDG-avid COVID-19 mRNA vaccine-related axillary lymphadenopathy.

MATERIALS AND METHODS

We retrospectively analyzed FDG-positive, pathology-proven, metastatic axillary lymph nodes in 53 breast cancer patients who had PET/CT for follow-up or staging, and FDG-positive axillary lymph nodes in 46 patients who were vaccinated with the COVID-19 mRNA vaccine. Radiomics features (110 features classified into 7 groups) were extracted from all segmented lymph nodes. Analysis was performed on PET, CT, and combined PET/CT inputs. Lymph nodes were randomly assigned to a training (n = 132) and validation cohort (n = 33) by 5-fold cross-validation. K-nearest neighbors (KNN) and random forest (RF) machine learning models were used. Performance was evaluated using an area under the receiver-operator characteristic curve (AUC-ROC) score.

RESULTS

Axillary lymph nodes from breast cancer patients (n = 85) and COVID-19-vaccinated individuals (n = 80) were analyzed. Analysis of first-order features showed statistically significant differences (p < 0.05) in all combined PET/CT features, most PET features, and half of the CT features. The KNN model showed the best performance score for combined PET/CT and PET input with 0.98 (± 0.03) and 0.88 (± 0.07) validation AUC, and 96% (± 4%) and 85% (± 9%) validation accuracy, respectively. The RF model showed the best result for CT input with 0.96 (± 0.04) validation AUC and 90% (± 6%) validation accuracy.

CONCLUSION

Radiomics features can differentiate between FDG-avid breast cancer metastatic and FDG-avid COVID-19 vaccine-related axillary lymphadenopathy. Such a model may have a role in differentiating benign nodes from malignant ones.

KEY POINTS

• Patients who were vaccinated with the COVID-19 mRNA vaccine have shown FDG-avid reactive axillary lymph nodes in PET-CT scans. • We evaluated if radiomics and machine learning can distinguish between FDG-avid metastatic axillary lymphadenopathy in breast cancer patients and FDG-avid reactive axillary lymph nodes. • Combined PET and CT radiomics data showed good test AUC (0.98) for distinguishing between metastatic axillary lymphadenopathy and post-COVID-19 vaccine-associated axillary lymphadenopathy. Therefore, the use of radiomics may have a role in differentiating between benign from malignant FDG-avid nodes.

[The 497th case: fever, anterior hypopituitarism, lymphadenopathy]

A 57-year-old woman was admitted to hospital with fever. She still had fever treated with multiple antibiotics, and no definite evidence for infection was found. Hypothermia and hypotension developed, and magnetic resonance imaging (MRI) examination showed enlarged anterior pituitary and multiple small nodular lesions with mild enhancement on the left side. Hormone replacement and anti-infection treatment were administrated, but fever did not improve. Remarkable lymphadenopathy was found in left supraclavicular area. The pathology of lymph node biopsy indicated peripheral T-cell lymphoma (not otherwise specified, NOS). Positron emission tomography-computed tomography (PET-CT) revealed hypermetabolism in multiple lymph nodes, infiltration of the liver and spleen. The final diagnosis were peripheral T-cell lymphoma with involvement of liver and spleen (stage Ⅳ) and anterior hypopituitarism. After chemotherapy, fever alleviated and the function of anterior pituitary recovered gradually.

Frequency and Outcomes of Ipsilateral Axillary Lymphadenopathy After COVID-19 Vaccination

This case series reports on the frequency and outcomes of breast imaging–identified ipsilateral axillary lymphadenopathy after recent COVID-19 vaccination among women.

[Diagnostic challenges in Kimura's disease]

Ultra-rare diseases occur with a frequency of 2 in 100 000 people or less. Kimura's disease (KD) affects less than 1 in 1 000 000 people. It is a benign, chronic inflammatory soft tissue disorder, accompanied by eosinophilia, raised immunoglobulin E (IgE) titer and the presence of painless subcutaneous masses, usually in the head and neck region. The disease was first described in 1948 and occurs at higher rates in Asia than in America or Europe.

A CASE REPORT

A 35-year-old man without past medical history presented to his family doctor for bilateral cervical lymphadenopathy accompanied by eosinophilia. Despite subsequent in-depth diagnostics, including fine-needle aspiration biopsy (FNAB) of the lymph nodes, the definitive diagnosis was not initially established. After following 2 months, a selective lymphadenectomy was performed, putting Hodgkin's lymphoma under suspicion. The image of positron emission tomography coupled with computed tomography (PET-CT) corresponded to this diagnosis. Due to the lack of all the criteria necessary to make a diagnosis, another histopathological consultation was done. The image of the lymph nodes suggested reaction-inflammatory changes. Due to the presence of a triad of signs (reactive lymphadenopathy, several eosinophils in the paracortic zone, vascular proliferation), differential diagnosis was recommended, among others towards the Kimura's disease. A series of examinations allowed to exclude lymphadenopathy of parasitic, allergic and hyperplastic hematopoietic system aetiology. The patient started steroid therapy with a good effect at first. However, after the recurrence of the disease, the patient was qualified to intensify the immunosuppressive treatment.

CONCLUSIONS

In the described case, the intensive diagnostic process and the thorough analysis of the test results relatively quickly led to the correct diagnosis. This enabled the implementation of appropriate treatment and prevented the initiation of empirical therapy for the originally diagnosed Hodgkin's lymphoma.

Clinicopathological Profile and 2 Year Relapse Rates of Non-Hodgkin's Lymphoma in Tertiary Care Center

The aim and objectives are to study clinicopathological profiles and 2-year relapse rates of Non-Hodgkin lymphoma,Material :This prospective observational study was conducted from Jan 2017 to May 2021. All newly diagnosed patients of NHL were enrolled and received a CHOP±R regimen for 6 cycles as per B-cell or T-cell lineage. The data was and analyzed using spss software. Observation: A total of 50 patients were enrolled and followed for 2 years. The median age of presentation was 44.62±15.92. Commonest clinical presentation was lymphadenopathy (46%), followed by B symptoms (32%). Commonest clinical sign was lymph node enlargement (52%). The commonest extranodal presentation was hepatomegaly (22%) and splenomegaly (22%). On peripheral blood smear, macrocytic hypochromic anemia (12%) was the commonest presentation. CT Scan showed, nodal involvement in 86% with generalized lymphadenopathy in (40%) cases. Extranodal involvement was seen in 50%. WB PET showed nodal involvement in (90%), and extranodal involvement in 70%. PET scan (90%) was a little more sensitive for detecting lymph node involvement over CT scan (86%). On lymph node biopsy, the most common subtype was B cell NHL (84.84%) and the commonest histopathological subtype was diffuse large cell B cell lymphoma. Biopsy from the extranodal site shown B cell NHL in (93.33%). The commonest histopathological subtype was DLBCL (18%). On marrow examination and biopsy, 88% were B cell type and the commonest type was DLBCL (62%). The commonest treatment-related toxicity was febrile neutropenia (44%). At 6 months, 30% were having clinical active disease and PET imaging revealed radiologic disease activity in 32 %. At 12 months, 14% were having clinical disease, and radiologic disease activity in 14%. At 18 months, 5% were having clinical disease, and radiologic disease activity in 10%. At 24 months, 14% were having clinical disease, and radiologic disease activity in 14%. At the end of the study period, 78 % were in remission, 10% cases in relapse, 6% cases had progressive disease and 6% of cases expired. Conclusion: This study found 02-year survival post standard chemotherapy in NHL cases was 88%. The relapse rate at 24 months was 14%. The B symptoms were seen less commonly, and bulky disease was noted in one-third of cases. The role of PET in diagnosing and follow up on these cases was good but it was comparable with CT scan.

COVID-19 vaccine associated axillary lymphadenopathy - A systematic review

INTRODUCTION

; COVID-19 vaccines are commonly administered intramuscularly to the arm. Axillary lymphadenopathy has been reported as an adverse event after COVID-19 vaccination. In patients with breast cancers who received COVID-19 vaccination, presence of ipsilateral (or contralateral) lymphadenopathy poses diagnostic dilemma. This systematic review aims to evaluate the incidence and clinical characteristics of vaccine associated axillary lymphadenopathy.

METHODS

; The systematic review was conducted with accordance to the PRISMA statement. The search terms used were "Vaccine" OR "Vaccination" AND "Lymphadenopathy" OR "Lymph node" AND "Covid-19″.

RESULTS

; 31 studies or reports were identified using the predefined keywords from the systematic review protocol. After excluding irrelevant papers (such as guidelines, reviews, opinions and commentaries), 10 studies or reports were included in the review.Pooled incidence of clinically detectable lymphadenopathy after COVID-19 vaccination was 91/22,532 (0.4%). Mean size of the vaccine associated axillary lymphadenopathy was 18.2 mm (Range 16 - 21 mm). Mean duration from vaccination to occurrence of axillary lymphadenopathy was 6.9 days (Range 2 - 18 days). In a study on 119 patients, enlarged axillary lymphadenopathy resolves in 4 to 5 weeks.

CONCLUSION

; Vaccine associated axillary lymphadenopathy is not uncommon. Management of it is based on multidisciplinary decision with patient demographics, vaccination history and radiological finding being taken into account. Additional imaging and biopsy may lead to unnecessary healthcare burden. Proper arrangement of vaccination and imaging regarding timing and laterality should be advocated to avoid confusion and patient anxiety.

Uncommon aetiology of lymphadenopathy in a healthy child: a sporotrichosis case with painless lymphadenopathy

A 6-year-old boy was referred to the paediatric infectious disease clinic with a 2-month history of enlarged, erythematous, painless cervical lymph nodes. He initially presented to his paediatrician with a painless lesion. At that time, he was treated empirically with clindamycin and azithromycin due to a history of cat exposure. Despite treatment, the lesion evolved into a non-healing linear ulcer with painless, ascending cervical lymphadenopathy. Serologies were negative for Bartonella henselae antibodies. Additional laboratory studies revealed eosinophilia and negative Toxoplasma gondii antibodies. After no improvement following a course of trimethoprim-sulfamethoxazole, further questioning revealed that the patient had fallen into a haystack 1 month before the initial cervical lesion. The patient's parents opted to treat the infection empirically for sporotrichosis with itraconazole rather than undergo lymph node biopsy. At the 2-week follow-up, his lymphadenopathy had resolved and had returned to baseline activity.