A “happy ending” of mediastinal and abdominal lymphadenopathy associated with hepatosplenomegaly and pulmonary lesions

Abstract

Major diagnosis for mediastinal and abdominal lymphadenopathy is lymphoma and tuberculosis. Spontaneous remarkable evolution should discuss viral infection on the condition that no corticosteroids have been taken before as they could magically improve an authentic lymphoma. Trial of antituberculosis treatment that is used in some cases could lead to a misdiagnosis as the viral‐infected patient can spontaneously heal as it is described in this case.

Major diagnosis for mediastinal and abdominal lymphadenopathy is lymphoma and tuberculosis. Spontaneous remarkable evolution should discuss viral infection on the condition that no corticosteroids have been taken before as they could magically improve an authentic lymphoma. Trial of antituberculosis treatment that is used in some cases could lead to a misdiagnosis as the viral‐infected patient can spontaneously heal as it is described in this case.

A 47‐year‐old woman with medical history of gastritis was admitted in the hospital in July 2019 for prolonged fever, arthralgia with asthenia, and significant loss of weight. Clinical examination showed fever (40°C), hepatosplenomegaly, and no signs of arthritis. Laboratory tests showed lymphopenia and a high level of C‐reactive protein (CRP), cholestasis, high level of lactate dehydrogenase (LDH) but normal levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT).

Endocarditis was initially ruled out. Hemoculture and transthoracic echocardiogram were in fact normal. Computed tomography (CT) showed mediastinal and abdominal lymphadenopathy (Figures 1 and 2), bilateral pulmonary micronodules with ground‐glass opacities (Figure 3), and hepatosplenomegaly with infarct zone of the spleen (Figure 4). Two major diagnostics were considered: tuberculosis and lymphoma.

Figure 1.

Evolution of mediastinal lymphadenopathy. A and C, CT of July 2019 showing subcarinal lymph node (red arrow) and right hilar node (yellow arrow). B and D, CT of August 2019 showing remarkable disappearance of the lymphadenopathy

Figure 2.

Evolution of abdominal lymphadenopathy. A and C, CT of July 2019 showing hepatic lymphadenopathy. B and D, CT of August 2019 showing remarkable disappearance of lymphadenopathy

Figure 3.

Evolution of hepatosplenomegaly. A: CT of July 2019. White arrow: infract zone of the spleen. B, CT of August 2019

Figure 4.

Evolution of bilateral pulmonary micronodules and ground‐glass opacities. A, CT of July 2019. B, CT of August 2019

Acid‐fast bacilli (AFB) smear and culture using sputum obtained from the patient were negative. AFB was also negative in bronchoalveolar lavage fluid. Polymerase chain reaction for Mycobacterium tuberculosis was negative too. Upper gastrointestinal endoscopy showed no signs of degenerative gastritis. Lymphoma was then highly suspected especially with high LDH values.

Within a week of admission, the patient underwent laparoscopic exploration to allow biopsy but no significant lymphadenopathy was found. After a few days, the patient went afebrile with significant clinical improvement without any treatment. Control laboratory tests were normal.

Follow‐up CT was performed after a month of evolution (August 2019) that showed remarkable improvement with almost complete disappearance of lymphadenopathy, pulmonary lesions, and a normalizing size of the liver and the spleen (Figures 1, 2, 3, 4).

Spontaneous remarkable evolution has reduced the diagnostic range leading to seek for viral infection. However, serologic tests for infectious mononucleosis, cytomegalovirus (CMV), and human immunodeficiency virus (HIV) excluded recent infection.

Clinical and biological follow‐up at 3 months was normal. Final diagnosis was nonbiologically proven viral infection.

1. TEACHINGS POINTS

• Major diagnosis for mediastinal and abdominal lymphadenopathy is lymphoma and tuberculosis.1

• Spontaneous remarkable evolution should discuss viral infection on the condition that no corticosteroids have been taken before as they could magically improve an authentic lymphoma.2

• Trial of antituberculosis treatment that is used in some cases could lead to a misdiagnosis as the viral‐infected patient can spontaneously heal as it is described in this case.

CONFLICT OF INTEREST

None declared.

AUTHOR CONTRIBUTION

BSF: took the pictures, wrote the text with the help of all the coauthors, and has no potential conflicts of interest, financial disclosures, and funding sources. TW: helped in writing the manuscript, reviewed the final version, helped in discussing the case, and has no potential conflicts of interest, financial disclosures, and funding sources. BA: helped with reviewing the manuscript and has no potential conflicts of interest, financial disclosures, and funding sources. SS: helped with diagnosis by reporting and comparing the two CTs and has no potential conflicts of interest, financial disclosures, and funding sources. BS: supervised all the work and has no potential conflicts of interest, financial disclosures, and funding sources.

Ben Salem F, Triki W, Belkhir A, Sbaihi S, Boukriba S. A “happy ending” of mediastinal and abdominal lymphadenopathy associated with hepatosplenomegaly and pulmonary lesions. Clin Case Rep. 2020;8:767–769. 10.1002/ccr3.2727