CHEST Guidelines-An-Immunocompetent-56-Year-Old-Woman-With-Multiple

An-Immunocompetent-56-Year-Old-Woman-With-Multiple

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The case involves a 56-year-old immunocompetent woman who presented with recurrent fevers and multiple enlarged lymph nodes, specifically in the mediastinum and bilateral supraclavicular regions. The patient’s history revealed no tobacco or alcohol use and no familial cancer history. Initial CT scans and a PET-CT showed multifocal lymphadenopathy. Comprehensive tests ruled out TB and other common malignancies and infections.<br /><br />Physical examination was unremarkable except for firm, mobile, non-tender lymph nodes. Blood tests showed elevated C-reactive protein and normal white blood cell counts. A lymph node biopsy suggested granulomatous inflammation with extensive necrosis but no neoplastic evidence. Significant plasma cell infiltration was noted, and immunohistochemistry results pointed towards a possible IgG4-related condition, with an elevated IgG4/IgG ratio.<br /><br />Molecular diagnostic techniques, including high-throughput sequencing and culturing, identified Rhizopus microsporus as the causative agent of a rare form of mucormycosis confined to lymph nodes. This finding was particularly unique considering the patient’s immunocompetent status.<br /><br />Mucormycosis, often associated with immunocompromised individuals, can have a high mortality rate if not identified and treated promptly. The patient was treated with intravenous amphotericin B and oral isavuconazole, resulting in significant clinical improvement and reduction in lymphadenopathy size without hepatic or renal side effects.<br /><br />The case underscores the importance of considering fungal infections in differential diagnoses for lymphadenopathy and highlights the efficacy of combined antifungal therapies even in atypical presentations of mucormycosis. Early diagnosis using fine-needle aspiration biopsy coupled with sequencing and culturing techniques can be crucial for timely and effective treatment.

Keywords

immunocompetent

lymphadenopathy

IgG4-related disease

mucormycosis

Rhizopus microsporus

antifungal therapy

amphotericin B

isavuconazole

granulomatous inflammation

fine-needle aspiration biopsy