This is a 10-year-old girl from the urban area of Medellin (Colombia), a black high school student, who consulted for a clinical picture of a month of evolution, consisting of intermittent adenoid headache, up to 40°C.
In the review by systems, he denied other symptoms.
He had received acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and amoxicillin without improvement.
Among his antecedents it was found that at 4 years of age he had presented a febrile syndrome that lasted three months and he gave up without leaving sequelae.
At that time, multiple tests were performed, including a bone marrow aspirate, without finding the cause.
Upon admission due to the current disease, the patient was in acceptable general hydrated conditions, with a temperature of 40.3°C and multiple painful left cervical lymphadenopathies, with a predominance of 2 cm x mobile skin.
No other adenomegaly or visceromegaly were found.
The rest of the physical examination was normal.
The patient was hospitalized with a diagnosis of adenitis cervicalis and antimony treatment was initiated.
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The initial laboratory tests found: leukopenia, 3.3 leukocytes x 109/L; neutrophils, 36%; lymphocytes, 36%; platelets, 230,000/mm3; hemoglobin, 10.3 g/dl; liver failure, 33%; reactive sedimentation rate
The neck ultrasound showed multiple left cervical lymphadenopathies along the jugular chain, those greater than 1.8 cm x 1.0 cm and 1.9 cm x 1.2 cm.
After 48 hours of treatment with isoniazid, high fever persisted and there was no change in lymphadenopathy.
It was decided to give antibiotic treatment with clindamycin, when there was suspicion of adenitis with abscesses, with which a slight decrease in the size of the lymphadenopathies and of the pain was achieved.
The results of laboratory tests performed as part of the etiological study of febrile syndrome showed: IgM and IgG antibodies against cytomegalovirus, dengue and Toxoplasma gondii, negative tuberculin skin test IgM / tuberculin skin test, negative IgM / tuberculin series, positive IgM / tuberculin skin test, IgM / tuberculin skin test, IgM / tuberculin skin test positive; IgM / tuberculin skin test, IgM / tuberculin skin test / tuberculin skin test, IgM / tuberculin +
A lymph node biopsy was performed in which coalescent areas of necrosis without caseification were observed, affecting 80% of the parenchyma, indicative of necrotizing lymphadenitis.
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After 20 days of hospitalization, there was a decrease in the size of the lymph nodes and fever was no longer daily but intermittent.
The cause of the fever was not clarified, but given the patient's stability and good general condition, it was decided to discharge him with evaluation by external consultation and review of the special stains of the material from the lymph node biopsy.
A month later, the patient was evaluated again, who reported that she had continued with fever almost daily from her hospital admission, with increased size of cervical lymph nodes.
The report of the special stains of the biopsy and immunohistochemistry indicated Kikuchi-type necrotizing lymphadenitis.
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Therapy with prednisone was initiated at a rate of 0.3 mg/kg/day, obtaining a rapid but transient response, with disappearance of the fever and decrease in the size of the lymph nodes one week after the onset of the steroid recurrence 10 days later.
Persistence of leukopenia (3.9 leukocytes x 109/L) and hypergammaglobulinemia were found, so the daily dose of prednisone was increased to 0.5 mg/kg. The patient required a progressive increase in the daily dose of
The total control of the disease was obtained at one month, with the addition of azathioprine to treatment.
The fever disappeared definitively, the lymphadenopathies and leukopenia resolved, and acute phase reactants returned to normal.
