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10-year-old boy presents with swollen lymph nodes, ulcerative lesions
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A 10-year-old boy presented last summer with several swollen lymph nodes in his left inguinal and left upper chest, along with sores on his abdomen and lower left chest. The sores were first thought to be poison ivy that he had acquired while clearing weeds from his grandmother’s rose garden 1 month earlier, and indeed, there were some lesions on his arm that were described as inflamed vesicular lesions that cleared with some topical steroid cream.
However, the sores on his chest and abdomen have persisted, along with the swollen lymph nodes on his chest (Figure 1) and left inguinal area (Figures 2 and 3). The lesions have been present for about 3 weeks and have changed from erythematous papules to ulcerative lesions (chest lesion) with slight drainage periodically.
The patient is otherwise a very healthy 10-year-old boy with no significant illnesses, surgeries or injuries in the past. He has been given two courses of oral antimicrobial therapy, consisting of clindamycin and Augmentin (amoxicillin/clavulanate, Dr. Reddy’s Laboratories) without benefit. His travel history includes a trip to Arizona 3 years ago but is otherwise unremarkable. The boy was exposed to two dogs and one cat in the household, yet he denies any scratches, and no ticks have been embedded and pulled off. He denies that he has done any camping but does swim in a local lake periodically. No one else in the household or any of his friends have exhibited similar lesions.
Examination reveals normal vital signs with an otherwise completely normal exam except for the lesions and swollen lymph nodes noted above. Lab tests performed by his primary care provider and in the infectious diseases clinic included a normal CBC and comprehensive metabolic panel; additionally, a fungal panel (Blastomyces, Coccidioides, Histoplasma), T-spot (gamma interferon release assay), tuberculin skin test, Epstein-Barr virus, cytomegalovirus, toxoplasma and Bartonella henselae antibodies, as well as a herpes simplex PCR of a viral swab of the chest lesion were all found to be negative. His chest radiograph is clear.
The chest node and lesion were biopsied, with stains for bacteria, fungi, acid-fast bacilli and silver staining organisms were all negative. Additionally, a mycobacteria PCR panel was performed on the tissue and was also negative. All cultures were negative, and the histologic examination of the lymph node revealed follicular lymphoid hyperplasia with small foci of granulation and chronic inflammation, compatible with infection; therefore, there were no confirmatory test results, like back in the old days when history, exam and common sense were all we had.
By the process of elimination, the best answer is lymphocutaneous sporotrichosis, based on the history of exposure (working in his grandmother’s rose garden) and chronic appearance; this was reinforced by a positive response to therapy with itraconazole for 3 months. Sometimes absolute proof by laboratory methods is not available, and one must rely on the history, clinical course, appearance and lastly on the response to therapy to arrive at the proper diagnosis. A different case of sporotrichosis, with more discussion was featured in the March 2011 column.
Cat-scratch disease does not necessarily require a history of being scratched by a cat, but usually there is some history of exposure to cats, particularly to kittens. Oftentimes, a granulomatous lesion or lesions appear at the scratch site (Figure 4). This may still be present when the patient presents with lymphadenopathy but has often already resolved by the time the patient presents for treatment. The granuloma can appear very similar to the lesion of early sporotrichosis. However, cat-scratch granulomas do not persist. Nowadays, antibody titers are usually useful in confirming or ruling out cat-scratch disease. Additionally, negative silver staining of the tissue would mitigate against cat-scratch disease. In the years before serologic methods were used to detect this organism, Warthin-Starry silver stain of biopsy tissue was one of the main ways of diagnosing cat-scratch disease, as the bacillus could be seen using this technique. A case of cat-scratch disease that was initially thought to be sporotrichosis was featured in the October 2015 issue.
Infections with nontuberculous mycobacteria can produce chronic granulomatous and ulcerative lesions of the skin (Figure 5). The most common variety is Mycobacterium marinum, which occurs when there is exposure to a source of contaminated water with injury of the skin. However, negative stains, cultures, PCR panel for mycobacteria and a negative tuberculin skin test make this choice very unlikely.
You may have noticed that I make reference to old columns much more now than in the past. The reason is to limit the space this column uses nowadays by trimming the discussion portion. I am interested in your feedback, so please feel free to send me your comments and questions.
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- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.