Marrow biopsy in the diagnosis of pyrexia of undetermined origin

Marrow from 62 cases of pyrexia of undetermined origin was examined cytologically, histologically, and bacteriologically. Diagnostic findings were present in five cases (8%), but all these patients presented definite clinical or haematological indications for marrow biopsy. It is concluded that marrow examination is useful in the diagnosis of pyrexia of undetermined origin but that cases for study must be selected in the light of general principles. Fever alone, even though prolonged and undiagnosed, is not an indication for marrow biopsy.     

Inflammatory pseudotumor of lymph nodes presenting as pyrexia of unknown origin

Inflammatory pseudotumor (IPT) is an uncommon benign disorder characterized by proliferation of spindle cells, inflammatory cells, and small vessels. The IPT of lymph nodes is a rare cause of lymphadenopathy that usually affects one or two nodal groups. We describe a 27-year-old male presenting with generalized lymphadenopathy, hepatosplenomegaly and fever for 1 year. Histologic examination of lymph node revealed few remnant lymphoid aggregates with marked sclerosis and numerous anastomosing blood vessels in lymph node parenchyma. Interspersed in between the fibrotic bands was a polymorphic infiltrate composed of lymphocytes, plasma cells, eosinophils, and immunoblasts. Also, many histiocytes, multinucleated giant cells some being Langhan's type and at places forming ill-defined granulomas were observed. The presence of granulomas and Langhan's type of giant cells can lead to a misdiagnosis of tuberculosis as was also done in the present case. It is thus not only important to be aware of this rare benign pathologic entity while dealing with a case of lymphadenopathy, but also consider it in the differential diagnosis of granulomatous disease.     

Malignant pheochromocytoma with cutaneous metastases presenting with hemolytic anemia and pyrexia of unknown origin

We describe a 43 year old female who presented with pyrexia of unknown origin associated with Coomb's negative hemolytic anemia and impaired liver function tests of six months duration. A routine abdominal computerised tomographic scan showed a mass in the left adrenal which was excised at laparotomy and histologically diagnosed as pheochromocytoma. The hemolysis continued to worsen with development of resistance to steroid therapy. Subsequently she developed multiple firm to hard painless cutaneous nodules which were aspirated for cytologic examination. The cytology picture was that of a neuroendocrine tumour with cell morphology similar to that of the adrenal pheochromocytoma. Such an association of hemolytic anemia, pyrexia and cutaneous metastases in a case of malignant pheochromocytoma has not been described earlier in the medical literature.     

Acquired immunodeficiency syndrome presenting as testicular tuberculosis

A 50 year old heterosexual male presented with fever and cough with expectoration of months duration, and swelling in the right testis. The serological tests showed positivity for HIV 1 and 11 antibodies. Testicular biopsy from the right testis showed epitheloid cell granulomas with central caseous necrosis and peripheral mantle of lymphocytes and plasma cells. Zeihl-Neelsen stain on tissue sections showed AFB positivity. To the best of our knowledge this is the second reported case of acquired immunodeficiency syndrome presenting as testicular tuberculosis.     

Cervico-mediastinal tuberculous lymphadenitis presenting as prolonged fever of unknown origin

Prolonged fever of unknown origin (FUO) is a challenging and important medical problem. Tuberculosis is the most frequent cause of FUO, especially in endemic regions, such as developing countries. We present a case of cervico-mediastinal tuberculous lymphadenitis that had been searched and followed up as a prolonged FUO. Especially in endemic areas, tuberculosis should be borne in mind in the differential diagnosis of FUO cases with granulomatous lymphadenitis presenting as prolonged or recurrent fever, even if the cultures and polymerase chain reaction for Mycobacterium tuberculosis are negative.     

Unilocular retroperitoneal cyst of mesothelial origin presenting as a renal mass

We report the first 2 cases, to our knowledge, of retroperitoneal cysts with features of mesothelial differentiation that clinically mimic renal masses. The first lesion occurred in a 71-year-old man who presented with flank pain. Ultrasound and magnetic resonance imaging studies showed a unilocular cystic structure arising from the upper pole of the left kidney. The second lesion was in a 44-year-old woman who presented with left flank pain. Imaging studies revealed an 8-cm hemorrhagic cyst at the lower pole of the left kidney. Histologic examination of the nephrectomy specimens in each case revealed a unilocular cyst with intracystic and pericystic hemorrhage. In each case, the cyst was lined by a single layer of cells with ample eosinophilic cytoplasm and benign nuclear features without mucinous or müllerian differentiation. Histochemical staining showed Alcian blue positivity on the cell surface, which was sensitive to hyaluronidase digestion. Intracytoplasmic mucin, however, was not detected. Immunostaining showed that the cyst lining cells were positive for keratin, vimentin, HBME-1, WT1, and thrombomodulin but negative for carcinoembryonic antigen, B72.3, Leu-M1, and BerEP4. The first case was positive for calretinin, whereas the second was negative. These findings support the mesothelial nature of the cysts.     

Miliary tuberculosis presenting as fever and jaundice with hepatic failure

A 58-year-old male patient with miliary tuberculosis presenting as jaundice and hepatic dysfunction was reported. He was admitted to the Miyazaki Medical College Hospital, Miyazaki, Japan, because of fever and jaundice. Chest x-ray revealed a calcified primary affect of tuberculosis in the left upper lung field and miliary shadows throughout both lung fields. Liver function tests showed indications of obstructive jaundice and hepatic dysfunction. He rapidly deteriorated and died 3 days after admission. Autopsy revealed disseminated miliary tuberculosis in all major organs. Many miliary tubercles were densely distributed in the liver, especially in and near the portal tracts. The intestine was free from tuberculous lesions. Miliary tuberculosis with jaundice is rare and its pathogenesis is discussed.     

Pancytopenia due to hemophagocytic syndrome as the presenting manifestation of tuberculosis

We report here an unusual hematologic manifestation of tuberculosis. A 40 year old male presented with pancytopenia due to hemophagocytic syndrome. Further investigations revealed he had tuberculosis.     

The great masquerader: Kikuchi-Fujimoto disease presenting as fever of unknown origin

IntroductionKikuchi-Fujimoto (KF) disease, also known as necrotizing histiocytic lymphadenitis, is a rare cause of fever of unknown origin. Most commonly seen in Japanese populations, it presents with fever and diffuse lymphadenopathy. KF can present a diagnostic challenge as its presentation can mimic sepsis, autoimmune disease, and/or malignancy. We present a case of KF disease presenting with innumerable pulmonary nodules and suspected sepsis.Case reportA 24-year old African-American male inmate with no past medical history presented to the Emergency Department with two witnessed generalized tonic-clonic seizures. Initial vitals were notable for a fever of 101.5 F, tachycardia, and tachypnea. He was lethargic with a diffuse, erythematous, scaly, necrotic rash. Additionally, cervical, axillary, and inguinal mobile, non-tender lymph nodes were noted. Laboratory studies revealed white blood cells 1.9 × 10 3 cells/μL with 25% bands, hemoglobin 9.4 G/dL, and platelet count of 110 × 10 3 cells/μL. He was subsequently admitted for sepsis due to presumed meningitis and started on broad-spectrum antibiotics. Lumbar puncture revealed no pleocytosis. Peripheral blood smear showed bandemia with Pelger Huet cells. Computed Tomography of chest, abdomen, and pelvis with contrast revealed diffuse pulmonary nodules involving all lobes of the lungs in addition to bulky hilar and retroperitoneal lymphadenopathy. Interventional Radiology performed a retroperitoneal lymph nodes biopsy that revealed lymphoplasmacytic cell infiltrate with extensive necrosis. Otolaryngology performed an excisional biopsy of a lymph node, which showed histiocytic necrotizing lymphadenitis. The final diagnosis was Kikuchi-Fujimoto disease, also known as histiocytic necrotizing lymphadenitis.OutcomeThe patient completed a 7-day course of empiric antibiotics. Workup for infectious etiologies was negative. The patient had a repeat CT of the chest with interval resolution of his pulmonary nodules on outpatient follow-up.ConclusionPatients with innumerable pulmonary nodules and fever of unknown origin should be evaluated early in their hospital course for KF as early diagnosis can reduce excessive testing and shorten hospital stay.     

Detection of mycobacteria in bone marrow biopsy specimens taken to investigate pyrexia of unknown origin.

AIMS--To investigate the value of bone marrow biopsy in the diagnosis of mycobacterial infection. METHODS--The culture results of 433 bone marrow samples taken between 1983 and 1992 were reviewed. The histopathology reports on bone marrow trephine specimens of culture positive samples and all those on HIV positive patients sent in 1992 were also reviewed. RESULTS--Fifty one specimens yielded Mycobacterium spp, 47 were obtained from HIV positive patients. Of the isolates, 42 were Mycobacterium avium-intracellulare (MAI), five were M tuberculosis (MTB), and the remaining four comprised a variety of atypical mycobacteria. All MAI positive samples were obtained from HIV positive patients, with the bone marrow being the only culture positive specimen in one third. Bone marrow yielded MTB only in patients from whom it was also isolated in other specimens. Eleven of 47 trephine specimens from positive bone marrow showed granulomata and nine showed acid-fast bacilli. No acid-fast bacilli were seen in the absence of granulomata. CONCLUSION--Bone marrow biopsy for mycobacterial culture should be reserved for severely immunosuppressed patients and should not be advocated for immunocompetent patients with suspected tuberculosis. Bone marrow biopsy still has a role in the investigation of pyrexia of unknown origin in HIV positive patients, despite the advent of mycobacterial blood culture techniques, particularly if these can be processed safely in automated systems.     

Disseminated nocardiosis in an elderly patient presenting with prolonged pyrexia: Diagnosis by thyroid abscess culture

We report a case of nocardiosis in an immunosuppressed elderly patient who presented with prolonged pyrexia. Nocardia asteroides was isolated from the thyroid, with CT scan evidence of dissemination to the brain, abdomen and lungs. The patient succumbed to illness despite aggressive therapy. Autopsy could not be performed. To the best of our knowledge, this is the first reported case from India, on Nocardia asteroides affecting the thyroid tissue.