The Diagnostic Performance of Magnetic Resonance Imaging in the Categorization of Pediatric Neck Lymph Nodes: Radiologic and Pathologic Correlations.

BACKGROUND/AIM: To present MRI features of neck lymph nodes in benign and malignant conditions in the pediatric population. MATERIALS AND METHODS: MRIs of the neck of 51 patients 1 to 18 years old (40 boys, 11 girls [10.08±4.73]) with lymph node biopsy were retrospectively analyzed. Those were grouped as benign including reactive (27 [52.9%]) and lymphadenitis (11 [21.6%]), and malignant (13 [25.5%]). The groups were evaluated multiparametrically in terms of quantitative and qualitative variables. RESULTS: The long axis, short axis, area, and apparent diffusion coefficient (ADC) values of the largest lymph node were 21 (17 to 24) mm, 14 (12 to 18) mm, 228.60 (144.79 to 351.82) mm 2 , 2531 (2457 to 2714) mm 2 /s for reactive, 24 (19 to 27) mm, 15 (11 to 20) mm, 271.80 (231.43 to 412.20) mm 2 , 2534 (2425 to 2594) mm 2 /s for lymphadenitis, 27 (23.50 to 31.50) mm, 20 (15 to 22) mm, 377.08 (260.47 to 530.94) mm 2 , 2337 (2254 to 2466) mm 2 /s for malignant, respectively. Statistical analysis of our data suggests that the following parameters are associated with a higher likelihood of malignancy: long axis >22 mm, short axis >16 mm, area >319 cm 2 , ADC value <2367 mm 2 /s, and supraclavicular location. Perinodal and nodal heterogeneity, posterior cervical triangle location are common in lymphadenitis ( P <0.001). Reactive lymph nodes are distributed symmetrically in both neck halves ( P <0.001). CONCLUSION: In the MRI-based approach to lymph nodes, not only long axis, short axis, surface area, and ADC, but also location, distribution, perinodal, and nodal heterogeneity should be used.

The spectrum of cytological findings in patients with BCG lymphadenitis: A series of 13 cases.

CONTEXT: Bacillus Calmette-Guérin (BCG) vaccine has been used to prevent tuberculosis and/or its severe complications for long. BCG lymphadenitis is a common complication of the vaccine, which is sometimes subjected to cytological examination. The aim of the study is to describe the cytological findings of BCG lymphadenitis. SETTINGS: The study was conducted in a tertiary care hospital in the western part of India from January 2021 to December 2022. DESIGN: The study was performed on archived material of all patients who were referred to the fine needle aspiration clinic for cytology examination. Clinical and pathological data of cases were retrieved, and cases of BCG lymphadenitis were selected in the study based on these data. Slides of cases were retrieved, and cytological findings were studied. MATERIALS AND METHODS: Papanicolaou, Giemsa, and Hematoxylin & eosin-stained smears, as well as Ziehl-Neelson stain (Z.N. stain) smears of all BCG lymphadenitis cases, were retrieved. Cases were reviewed for individual cytological features and overall cytological diagnostic categories. Z.N. stain smears were evaluated for acid-fast bacilli. RESULTS AND CONCLUSIONS: Diagnostic categories observed in BCG lymphadenitis include suppurative lymphadenitis/abscess (15 %), necrotizing lymphadenitis (23 %), necrotizing granulomatous lymphadenitis (46 %), suppurative granulomatous lymphadenitis (8 %), non-necrotizing granulomatous lymphadenitis (8 %). Acid-fast bacilli were detected by Z.N. stain in 8 cases (62 %). The cytological findings of BCG lymphadenitis closely overlap with those of tuberculous lymphadenitis. So, clinical context is very important while reporting isolated axillary lymphadenopathy, specifically in recently vaccinated infants, to avoid misdiagnosis as tuberculous lymphadenitis.

A classic case of scrofula-cervical tuberculous lymphadenitis.

Tuberculosis (TB) is considered a common infection in developing countries and is caused by various strains of mycobacteria, usually Mycobacterium TB. TB remains to be one of the most important health threats. TB can have varied clinical presentations; Pulmonary TB affects the lungs and extrapulmonary TB (EPTB) can affect any part of the body. Cervical tuberculous lymphadenitis (CTL), cervical lymphadenitis, which is also referred to as scrofula is a case of EPTB that most frequently involves the cervical lymph nodes. In our report, a case of a young patient with CTL has been reported. This case's physical examination, evolution, diagnosis, and treatment have been discussed. Our case exemplifies the potential manifestations of an extrapulmonary tubercular lesion of the posterior pharyngeal wall, demonstrating that mycobacteria can infect practically any human organ. A high index of suspicion is critically required for the diagnosis of tuberculous lymphadenitis as mimics a number of pathological conditions.

Observer- and radiomics model-based computed tomography classification of suppurative versus tuberculous lymphadenitis complicated with nodal necrosis of the neck in children.

BACKGROUND: Computed tomography (CT) can be used for the early detection of lymphadenitis. Radiomics is able to identify a large amount of hidden information from images. However, few CT-based radiomics studies on cervical lymphadenitis in children have been published. OBJECTIVE: This study aimed to investigate the role of visual CT analysis and CT radiomics in differentiating cervical suppurative node necrosis from tuberculous node necrosis in pediatric patients. MATERIALS AND METHODS: A total of 101 patients with cervical suppurative lymphadenitis (n=52) or cervical tuberculous lymphadenitis (n=49) were included. Clinical data and CT images were retrieved for analysis. For visual observation, 11 major CT features were identified for univariate and multivariate analyses. For radiomics analysis, image segmentation, feature value extraction, and dimension reduction, feature selection and the construction of radiomics-based models were performed through the RadCloud platform. RESULTS: For the visual observation, significant differences were found between the two groups, including the short diameter of the largest necrotic lymph node (P=0.03), sharp border of the node (P=0.02), fusion of nodes (P=0.02), regular silhouette of the necrotic area (P=0.001), multilocular necrotic area (P=0.02), node calcification (P=0.004), and enhancement degree of the nodal nonnecrotic area (P=0.01). No feature was found to be an independent predictor for suppurative or tuberculous lymphadenitis (P>0.05 for all features). Concerning the radiomics analysis, after feature value extraction and dimension reduction, nine related features were selected. The support vector machine classifier achieved high diagnostic performance in distinguishing suppurative from tuberculous lymphadenitis. The area under the curve, accuracy, sensitivity, and specificity of the support vector machine model test set were 0.89 (95% confidence interval: 0.72-1.00), 0.88, 0.78, and 0.90, respectively. CONCLUSION: Compared to observer-based CT image analyses, radiomics model-based CT image analyses exhibit better performance in the differential diagnosis of cervical suppurative and tuberculous lymphadenitis complicated with nodal necrosis in children.

[Pathological significance of plasma cell infiltration in diagnosing lymph node diseases].

Objective: To investigate the value of plasma cells for diagnosing lymph node diseases. Methods: Common lymphadenopathy (except plasma cell neoplasms) diagnosed from September 2012 to August 2022 were selected from the pathological records of Changhai Hospital, Shanghai, China. Morphological and immunohistochemical features were analyzed to examine the infiltration pattern, clonality, and IgG and IgG4 expression of plasma cells in these lymphadenopathies, and to summarize the differential diagnoses of plasma cell infiltration in common lymphadenopathies. Results: A total of 236 cases of lymphadenopathies with various degrees of plasma cell infiltration were included in the study. There were 58 cases of Castleman's disease, 55 cases of IgG4-related lymphadenopathy, 14 cases of syphilitic lymphadenitis, 2 cases of rheumatoid lymphadenitis, 18 cases of Rosai-Dorfman disease, 23 cases of Kimura's disease, 13 cases of dermal lymphadenitis and 53 cases of angioimmunoblastic T-cell lymphoma (AITL). The main features of these lymphadenopathies were lymph node enlargement with various degrees of plasm cell infiltration. A panel of immunohistochemical antibodies were used to examine the distribution of plasma cells and the expression of IgG and IgG4. The presence of lymph node architecture could help determine benign and malignant lesions. The preliminary classification of these lymphadenopathies was based on the infiltration features of plasma cells. The evaluation of IgG and IgG4 as a routine means could exclude the lymph nodes involvement of IgG4-related dieases (IgG4-RD), and whether it was accompanied by autoimmune diseases or multiple-organ diseases, which were of critical evidence for the differential diagnosis. For common lesions of lymphadenopathies, such as Castleman's disease, Kimura's disease, Rosai-Dorfman's disease and dermal lymphadenitis, the expression ratio of IgG4/IgG (>40%) as detected using immunhistochemistry and serum IgG4 levels should be considered as a standard for the possibility of IgG4-RD. The differential diagnosis of multicentric Castleman's diseases and IgG4-RD should be also considered. Conclusions: Infiltration of plasma cells and IgG4-positive plasma cells may be detected in some types of lymphadenopathies and lymphomas in clinicopathological daily practice, but not all of them are related to IgG4-RD. It should be emphasized that the characteristics of plasma cell infiltration and the ratio of IgG4/IgG (>40%) should be considered for further differential diagnosis and avoiding misclassification of lymphadenopathies.

Successful treatment with laparoscopic extended posterior sectionectomy for inflammatory pseudotumor in the liver with para-aortic lymphadenitis.

Inflammatory pseudotumor (IPT) is a rare disease that requires a differential diagnosis from malignancies. We describe a case of hepatic IPT with para-aortic lymphadenopathy, treated with a stepwise strategy of laparoscopic surgery. A 61-year-old woman was referred with a liver lesion. Computed tomography revealed a 13 cm well-defined lesion in segments VII-VI. The patient also had bead-like enlarged lymph nodes from the perihilar to the para-aortic regions. Although percutaneous lymph node biopsy showed no evidence of malignancy, 18 F-fluorodeoxyglucose positron emission tomography revealed accumulation in the lesion and lymph nodes. Lymph nodes were harvested laparoscopically for intraoperative pathological examination. With no evidence of malignancy, laparoscopic liver resection was continuously performed as a diagnostic treatment. The patient was given a pathological diagnosis of IPT and was discharged on the 16th day and is well 2 years after surgery. The minimally invasive laparoscopic approach to diagnostic treatment could be useful with secure advantages.

Case Report: Lepromatous Leprosy Masquerading as Acute Suppurative Lymphadenitis.

Leprosy is a chronic cutaneous infection. It is usually characterized by thickened nerves and maculo-anesthetic patches. Leprosy often has an unusual presentation, which is a diagnostic challenge. In this case report, we present a case of an elderly male who presented with fever and chronic pus-draining axillary, cervical, and inguinal lymph nodes. He also had a weak left foot for the previous 5 months. During his hospital stay, he developed additional papular lesions over his extremities. We performed fine needle aspiration from the lymph nodes and skin biopsy, which were suggestive of lepromatous leprosy. We initiated him on antileprosy medication. On follow-up, he was responsive to therapy. Although skin and nerve involvement in leprosy is common, this case had an atypical presentation of discharging lymph nodes.

A retrospective analysis of 1019 cases of tuberculous cervical lymphadenitis in a rural setup in 20 years.

BACKGROUND: This article is to review cervical lymphadenitis due to tuberculosis (TB), their presentation, their aetiology, the methods used to diagnose them, the treatment modalities offered and the response to treatment. METHODS: 1019 patients were diagnosed and treated for TB of the lymph nodes of the neck from 1st November 2001 to 31st August 2020 at a tertiary ENT hospital, Nadiad, Gujarat, India. Study consisted about 61% males and 39% females with the mean age being 37.3 years. RESULT: Commonest factor or habit among those diagnosed for tuberculous cervical lymphadenitis was consumption of unpasteurized milk. HIV and diabetes were the most common co-morbid conditions found with this disease. Swelling in the neck was most common clinical feature followed by loss of weight, formation of abscess, fever and fistula. Rifampicin resistance was found in 1.5% of patients among those tested for the same. CONCLUSION: The most commonly affected site for extra pulmonary TB is posterior triangle of neck than the anterior triangle. Patients with HIV and diabetes are at higher risk for the same. Testing for drug susceptibility has to be done due to increased resistant of drugs for extra pulmonary TB. GeneXpert and histopathological examination are important for its confirmation.

Diagnostic utility of fine-needle aspiration cytology in syphilitic lymphadenitis: A case report.

Syphilis is a sexually transmitted infection that causes serious health problems without treatment. Detection of syphilis is necessary to stop the spread of the infection. Cytological screeners and pathologists may experience fine-needle aspiration cytology (FNAC) for syphilitic lymphadenitis; however, its characteristic cytological features are rarely reported. We present FNAC cytological features of syphilitic lymphadenitis in a case of a 21-year-old man. He presented with a sore throat and painful neck lymphadenopathy. His swollen and painful neck persisted even with antibiotic treatment. Necrotizing lymphadenitis and lymphoma were clinically suspected. FNAC was taken from the swollen lymph node. Cytologic findings of the specimen showed various inflammatory cells with small-sized vessels arranged in a branching/arborizing fashion. The vessels were surrounded by inflammatory cells, including plasma cells, neutrophils, and macrophages. Perivascular plasma cell cuffing was focally seen along with inconspicuous granulomas. Neutrophils appeared to involve the vascular wall. The cytological findings suggested syphilitic lymphadenitis, and clinical findings and serological tests confirmed primary syphilis with concomitant human immunodeficiency virus infection. Branching/arborizing vessels associated with many plasma cells, vascular involvement of neutrophils, and granulomas may suggest syphilitic infection if the specimen is obtained via FNAC. (189 words).

Exploring the immunological basis of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome: immunohistochemical staining features of palatine tonsils.

OBJECTIVES: Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is the most common periodic fever syndrome during early childhood period with regular febrile attacks of sterile upper airway inflammation. The cessation of attacks following tonsillectomy points to fundamental role of tonsil tissue on etiopathogenesis of disease, which is not clarified satisfactorily. The aim of this study is to explore the immunological basis of PFAPA by evaluating the cellular properties of tonsils, and microbial exposition such as Helicobacter pylori on tonsillectomy materials. METHODS: The paraffinized tonsil samples of 26 PFAPA and 29 control patients with obstructive upper airway disorder were compared in terms of immunohistochemical staining features including CD4, CD8, CD123, CD1a, CD20, and H. pylori. RESULTS: The median number of CD8+ cells was 1485 (1218-1287) in PFAPA while it was 1003 (852-1261.5) in control group and the difference was statistically significant (p=0.001). Similarly, CD4+ cell counts were statistically higher in PFAPA group than control (833.5 vs 622). The ratio of CD4/CD8 did not differ between two groups; also, there was no statistically difference in terms of the other immunohistochemical staining results, such as CD20, CD1a, CD123 and H. pylori. CONCLUSION: This is the largest number of pediatric tonsillar tissue study of PFAPA patients in current literature and we emphasized the triggering effects of CD8+ and CD4+ T-cells on PFAPA tonsils. KEY POINTS: • The cessation of attacks following tonsillectomy points to fundamental role of tonsil tissue on etiopathogenesis of disease, which is not clarified satisfactorily. • In current study, 92.3% of our patients did not experience any attacks following operation similarly with literature. • We observed the increased number of CD4+ and CD8+ T cell counts on PFAPA tonsils compared to control group and emphasized the active role of both CD4+ and CD8+ cells localized on PFAPA tonsils in immune dysregulation. • Some other cell types evaluated in this study such as CD19+ (B cells), CD1a (dendritic cells), and CD123 (IL-3 receptors, for pluripotent stem cells) and H. pylori did not differ in PFAPA patients compared to the control group.

Delayed diagnosis of bacterial cervical lymphadenitis in the tropics: a case report.

BACKGROUND: Lymphadenopathy refers to any disease process involving lymph nodes that are abnormal in size and consistency. There are multiple etiologies in the setting of a diseased lymph node, including conditions of infection, autoimmune diseases, and neoplasia. Lymphadenitis is a term that refers to lymphadenopathies that are due to inflammatory processes and can represent an acute bacterial infection resulting from streptococcal pharyngitis or a prior viral upper respiratory infection. Cervical lymphadenopathy refers to nodal swelling in the neck region. While cervical lymphadenitis is a common clinical finding in the setting of a transient response to a benign local or generalized infection, it may evade detection sometimes and thus account for a percentage of misdiagnosis or delayed diagnosis in the tropics. This case report is aimed at increasing the awareness about the presentation of bacterial cervical lymphadenitis and how it can sometimes mimic the presentation that is typical and regularly found with plasmodiasis. It contributes to improved awareness and high index of suspicion in clinic when dealing with patients in the tropics. CASE PRESENTATION: We present a case of delayed diagnosis of bacterial cervical lymphadenitis that initially presented with typical features of malaria from Plasmodium falciparum. A 26-year-old Nigerian woman presented to the outpatient department following complaints of a recurring fever of a month's duration and bilateral neck swelling of about 2 weeks prior to presentation. CONCLUSION: In the setting of a busy clinic, details are easily missed and salient features in the presentation of a patient that are needed for accurate diagnosis and management could go unrecognized. Hence, this case report highlights the importance of proper examination particularly of lymph nodes and use of different diagnostic modalities for the exact diagnosis of disease.

Cryptococcal lymphadenitis-First presentation in an HIV-positive patient.

Cryptococcal infection is a life-threatening, opportunistic infection in human immunodeficiency virus-infected individuals. The infection most commonly begins in the respiratory tract, with secondary involvement of the brain, skin, and lymph nodes. We report a rare case of isolated cervical cryptococcal lymphadenitis diagnosed on fine needle aspiration cytology, which was the initial presentation of secondary immunodeficiency in the patient. Periodic acid-Schiff stain, India ink preparation, and culture were done to confirm the diagnosis. He was diagnosed as HIV-positive on further investigation.

The Diagnostic Yield of Excisional Biopsy in Cervical Lymphadenopathy: A Retrospective Analysis of 158 Biopsies in Adults.

OBJECTIVES: Cervical lymph nodes are the most common site of peripheral lymphadenopathy. The underlying etiologies are usually benign and self-limiting but may include malignancies or other severe life-threatening diseases. The aim of the current study was to investigate the various underlying pathologies of cervical lymphadenopathy as assessed by the diagnostic yield of excisional lymph node biopsies of the neck in a tertiary adult practice. The evaluation was performed in light of previous literature and regional epidemiological patterns. METHODS: Retrospective analysis of hospital charts of 158 adult patients who underwent an excisional biopsy for suspected cervical lymphadenopathy at a tertiary referral head and neck service between January 2017 and December 2019. RESULTS: The most common underlying pathology was unspecific and/or reactive lymphadenitis in 44.5% of specimens, followed by malignant disease in 38.6% of cases. An age above 40 years was significantly correlated with an increased likelihood of malignant disease. Lower jugular and posterior triangle lymph nodes showed higher malignancy rates than other groups (100% and 66.7%, respectively). The overall surgical complication rate was 2.5%. CONCLUSIONS: The results of the current study serve as an indicator of the variety of etiologies causing cervical lymphadenopathy. In particular, given the increasing incidence of malignant diseases in recent decades, the findings should alert physicians to the importance of lymph node biopsy for excluding malignancy in persistent cervical lymphadenopathy especially in older adults. The findings emphasize the value of excisional lymph node biopsy of the neck as a useful diagnostic tool in adult patients with peripheral lymphadenopathy.

Coexistent Rosai Dorfman disease and Langerhans cell histiocytosis in an Orbital mass: A Case Report.

INTRODUCTION: Rosai Dorfman disease (RDD) is a rare benign histiocytic proliferative disorder of lymph node sinuses. Langerhans cell histiocytosis (LCH) is a solitary or multisystem clonal proliferation of abnormal dendritic cells (Langerhans cells) with varied presentations. The co-occurrence of these two entities is quite rare. CASE DESCRIPTION: A six-year-old boy presented with multiple mass lesions in the neck since two years and a nodular lesion in right upper eyelid for the past 4 months. He was diagnosed with tubercular lymphadenitis 2 years back, and was given a course of anti-tubercular therapy (ATT) elsewhere. No improvement was seen. Fine needle aspiration cytology (FNAC) of the cervical lymph nodes revealed reactive lymphadenitis while lymph node biopsy showed features of RDD. Excision biopsy of the orbital mass showed features of both RDD and LCH. The patient was started on tablet prednisolone. Six months later, complete resolution of lymph node enlargement and remaining orbital mass was noted. Post operative contrast enhanced Magnetic Resonance Imaging of head and neck was normal. CONCLUSION: The coexistence of RDD and LCH may be a result of divergent differentiation from a common lineage or a de novo phenotypic evolution.

A Case Report of Burkholderia mallei Infection Leading to Pneumonia.

BACKGROUND: Glanders is a rare zoonotic disease caused by Burkholderia mallei. Humans can be infected by B. mallei, which causes cutaneous lymphadenitis and pneumonia, leading to sepsis and death in severe cases. CASE PRESENTATION: We report a case of a 60-year-old male who was diagnosed with glanders. The patient who had a history of diabetes presented with cough, expectoration, and fever. Computed tomography (CT) imaging showed B. mallei infection in the right upper lobe of the lung with mediastinal lymph node involvement and the lingual segment of the left lung. Moreover, the posterior basal segment of the lower lobe of both lungs had inflammation. Subsequently, B. mallei infection was confirmed by lymph node biopsy and bronchoalveolar lavage multiplex PCR-based targeted gene sequencing. After meropenem treatment, the patient was discharged, and CT imaging showed reduced absorption of pulmonary inflammatory lesions. CONCLUSIONS: Glanders is a rare disease that can cause skin infection, lymphadenitis, and pneumonia, and in severe cases, it can be life-threatening. The diagnosis of this disease mainly relies on microbiological culture and pathological biopsy. Diagnosis is also facilitated by multiplex PCRbased targeted gene sequencing. Glanders is treated with cephalosporins, carbapenems, and other sensitive antibiotics.

Clinical scoring approach for detection of histiocytic necrotising lymphadenitis in adults.

BACKGROUND: Histiocytic necrotising lymphadenitis (HNL) is rare and can be easily ignored. AIMS: To summarise the characteristics of HNL and find a simple scoring approach to detect HNL in adult patients. METHODS: Adult patients with lymphadenopathy diagnosed by lymph node biopsy were enrolled. Chi-squared test and t-test were used to determine the significant variables. The cut-off values and scores assigned to each factor were performed by receiver operating characteristic (ROC) curves and coefficients in the logistic regression respectively. The performance of the scoring system was evaluated by ROC curves. RESULTS: There were 32 HNL cases and 1162 other cases in the present study. These features, including age, the frequency of presentations of fever, cervical and painful lymph nodes, decrease of white blood cells (WBC), ratio of neutrophil to WBC (N ratio) and elevated lactate dehydrogenase (LDH), were different between patients with HNL and other diseases. Based on the multivariate analysis, the scoring approach was defined as follows: score = 3 (fever) + 2 (cervical lymphadenopathy) + 2 (decreased WBC) + 1 (decreased N ratio) + 2 (elevated LDH). The cut-off was score 4. This approach performed will detect HNL with an area under the curve of 0.889. CONCLUSION: The present study suggests that the novel scoring approach we put forward might be useful to detect HNL in adult patients though further studies are needed.

Optimizing the endoscopic diagnosis of mediastinal lymphadenopathy: a glimpse on cryobiopsy.

Etiological diagnosis of mediastinal lymphadenopathy represents a daily challenge. Endosonography (transesophageal and transbronchial ultrasound-guided needle aspiration) is the recommended technique in the first diagnostic work-up and in the mediastinal staging of lung cancer. Despite a good sensitivity, limited amount of collected tissue may hamper molecular assessment in advanced lung cancer and in the diagnosis of lymphoproliferative disorders, fibrotic sarcoidosis, and mycobacterial lymphadenitis. Cryobiopsy, a bronchoscopic technique based on cooling, crystallization, and subsequent collection of tissue, has been successfully employed in the diagnosis of interstitial lung diseases. Cryoprobes provide larger amount of tissue than conventional bronchoscopic sampling tools and might potentially prevent the need for invasive surgical procedures. New applications of the technique (e.g., bronchoscopic diagnosis of peripheral pulmonary lesions and mediastinal lymph nodes) have been recently described in few reports. In a recent issue of the Journal, Genova et al. described five patients who underwent endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) followed by ultrasound-guided transbronchial cryobiopsy of mediastinal lymphadenopathy for a suspected malignancy. The authors discussed about the potential added value of mediastinal cryobiopsy on a correct histopathological and molecular assessment in patients with malignancies. EBUS-cryobiopsy could be a promising technique in the diagnostic pathway of mediastinal lymphadenitis. However, cryobiopsy is now available only in few selected centres. The learning curve of the technique adapted to mediastinal ultrasound-guided sampling, the optimal sampling strategy, its true diagnostic accuracy in patients with malignant and benign diseases, as well as its safety, are still largely unclear. Mediastinal cryobiopsy could be complementary rather than alternative to conventional endosonography. Rapid on-site evaluation of EBUS-TBNA could guide subsequent sampling with cryoprobes in case of poor collection of biological material or in case of suspected lymphoproliferative disorders. Further studies should investigate its diagnostic yield, in comparison or in combination with conventional endosonography, in large cohorts of patients with malignant or benign mediastinal lymphadenopthies.

Herpes simplex virus lymphadenitis is associated with tumor reduction in a patient with chronic lymphocytic leukemia.

BackgroundHerpes simplex virus lymphadenitis (HSVL) is an unusual presentation of HSV reactivation in patients with chronic lymphocytic leukemia (CLL) and is characterized by systemic symptoms and no herpetic lesions. The immune responses during HSVL have not, to our knowledge, been studied.MethodsPeripheral blood and lymph node (LN) samples were obtained from a patient with HSVL. HSV-2 viral load, antibody levels, B and T cell responses, cytokine levels, and tumor burden were measured.ResultsThe patient showed HSV-2 viremia for at least 6 weeks. During this period, she had a robust HSV-specific antibody response with neutralizing and antibody-dependent cellular phagocytotic activity. Activated (HLA-DR+, CD38+) CD4+ and CD8+ T cells increased 18-fold, and HSV-specific CD8+ T cells in the blood were detected at higher numbers. HSV-specific B and T cell responses were also detected in the LN. Markedly elevated levels of proinflammatory cytokines in the blood were also observed. Surprisingly, a sustained decrease in CLL tumor burden without CLL-directed therapy was observed with this and also a prior episode of HSVL.ConclusionHSVL should be considered part of the differential diagnosis in patients with CLL who present with signs and symptoms of aggressive lymphoma transformation. An interesting finding was the sustained tumor control after 2 episodes of HSVL in this patient. A possible explanation for the reduction in tumor burden may be that the HSV-specific response served as an adjuvant for the activation of tumor-specific or bystander T cells. Studies in additional patients with CLL are needed to confirm and extend these findings.FundingNIH grants 4T32CA160040, UL1TR002378, and 5U19AI057266 and NIH contracts 75N93019C00063 and HHSN261200800001E. Neil W. and William S. Elkin Fellowship (Winship Cancer Institute).