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Adolescent With Lymphadenopathy in the Absence of Systemic Symptoms

A 17-year-old adolescent male from Saudi Arabia presented to us for evaluation of abdominal and cervical lymphadenopathy. The patient was previously healthy until 5 months prior to presentation when he developed radiating lumbar pain. Worsening pain associated with difficulty ambulating prompted a spine magnetic resonance imaging at an outside institution which revealed disk protrusion at L4-L5. His back pain spontaneously resolved within 1 month. However, the spine MRI demonstrated an incidental finding of mesenteric lymphadenopathy. He denied any systemic symptoms. He was referred to a hematologist in Saudi Arabia and computed tomographic imaging revealed splenomegaly as well as mildly enlarged cervical, abdominal, pelvic, and inguinal lymph nodes. His C-reactive protein (CRP) was elevated at 17 mg/L and erythrocyte sedimentation rate (ESR) was also high at 31 mm/h. His white blood cell count was 8900 cells/mm with 57% neutrophils. He underwent an open biopsy of one of the enlarged mesenteric lymph nodes and a pathologic diagnosis of follicular hyperplasia was made. To explore the etiology of these findings, serologies for HIV, Toxoplasma gondii, and Brucella spp were performed and were negative. QuantiFERON-TB testing was negative. His lymphadenopathy was diagnosed as reactive without an identifiable etiology. The family was concerned for a serious systemic disease so they sought a second opinion at our institution. At the time of our evaluation, he was asymptomatic other than the recent onset of upper respiratory symptoms. He had a mild cough that improved over several days without antimicrobial intervention. He reported that he had exposure to horses and he periodically drank unpasteurized goat’s milk. His physical examination was unremarkable other than shotty cervical lymphadenopathy. Our laboratory evaluation revealed a white blood cell count was 7400/mm with 48% neutrophils. He had a mild microcytic hypochromic anemia with hemoglobin of 12.3 g/dL and mean corpuscular volume of 74.2 fL. Ferritin was normal at 25 μg/L. Liver function tests were within normal limits (alanine transaminase 21 U/L, aspartate transaminase 21 U/L, alkaline phosphatase 118 U/L, total and direct bilirubin of 0.3 mg/dL and 0.1 mg/dL, respectively). The ESR was normal at 12 mm/h but CRP was elevated at 23.3 mg/L. A CRP performed 4 days later was 10.2 mg/L, coincident with resolution of his upper respiratory symptoms. This near normalization suggests CRP elevation was related to his upper respiratory symptoms. Review of the original computed tomographic imaging confirmed mild enlargement of the spleen as well as abdominal, pelvic and inguinal lymph nodes. Serologies for HIV, Bartonella spp, Leishmania spp, Toxoplasma gondii, and Epstein-Barr virus were negative with normal immunoglobulin levels. QuantiFERON-TB testing was negative. Cytomegalovirus testing revealed negative IgM with positive IgG consistent with past infection. A Brucella spp serology showed a negative IgM but positive IgG. This was confirmed with an elevated serum agglutination titer of 1:320 (reference 1:80). Pathologist review at Mayo Clinic of the original lymph node biopsy revealed follicular lymphoid hyperplasia, monocytoid B-cell hyperplasia, and focal clusters of epithelioid histiocytes encroaching on follicle centers.