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Clinical Challenge
August 2016

A Woman With Bilateral Cervical Lymphadenopathy

Author Affiliations
  • 1Department of Otolaryngology, Head and Neck Surgery, Washington University in St. Louis, St Louis, Missouri
  • 2Infectious Disease Division, Department of Internal Medicine, Washington University in St Louis, St Louis, Missouri
JAMA Otolaryngol Head Neck Surg. 2016;142(8):799-800. doi:10.1001/jamaoto.2016.0021

A woman in her 50s with a history of ulcerative colitis presented with severe diffuse sore throat associated with fevers, chills, night sweats, and neck swelling of 2 weeks’ duration. Results from a rapid strep test were negative, and observation was initiated for presumed viral pharyngitis. Progression of neck swelling led to empirical treatment for bacterial pharyngitis. A neck computed tomographic scan with contrast revealed large bilateral asymmetric conglomerations of necrotic cervical lymph nodes measuring up to 9 cm in the greatest dimension (Figure, A). Four weeks after symptom onset, the patient was referred to the otolaryngology service. Initial evaluation, including fiber-optic laryngoscopy, revealed the presence of significant bilateral tender lymphadenopathy in the absence of any lesions in the upper aerodigestive tract. A core biopsy specimen yielded negative gram stain and aerobic and anaerobic bacterial, fungal, and acid-fast bacillus cultures. Polymerase chain reaction (PCR) of nodal contents was negative for Bartonella henselae. A chest radiograph was normal. Necrotic skin changes and persistent purulent neck drainage through the needle biopsy site required incision and drainage as well as incisional biopsy of the left side of her neck. Operative findings included abundant purulent debris and considerable necrosis of skin and neck musculature. All the cultures once again returned with no growth. Final pathologic examination showed necrotizing granulomatous inflammation (Figure, B) with no monoclonal lymphocyte population on flow cytometry. Results from a test for human immunodeficiency virus and angiotensin-converting enzyme testing were negative. Francisella tularensis serum antibody titers were 1:640.