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November 05, 2007 by Mark Brissette, MD

November 05, 2007 by Mark Brissette, MD. Case 1. 37-year old man with a 2 year history of an enlarged right inguinal lymph node. Diagnosis. Reactive Follicular Hyperplasia. Key Points. Lymph node architecture intact Germinal centers are surrounded by intact mantle zones

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November 05, 2007 by Mark Brissette, MD

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  1. November 05, 2007 by Mark Brissette, MD

  2. Case 1 • 37-year old man with a 2 year history of an enlarged right inguinal lymph node.

  3. Diagnosis • Reactive Follicular Hyperplasia

  4. Key Points • Lymph node architecture intact • Germinal centers are surrounded by intact mantle zones • Often see polarization of cells in germinal center (dark and light areas) • Tingible-body macrophages and mitoses present in germinal centers • Bcl-2 negative in germinal centers

  5. DDx • Follicular lymphoma (bcl-2 positive)

  6. Case 2 • 20-year old woman with an enlarged left neck lymph node for 4-5 months. FNA was consistent with a benign lymph node.

  7. Diagnosis • Toxoplasma lymphadenitis

  8. Key Points • Reactive follicular hyperplasia • Epithelioid microgranulomas scattered throughout node but characteristically in mantle zone and germinal center • Foci of monocytoid B-cell hyperplasia • Most commonly involves cervical nodes

  9. DDx • Other non-necrotizing granulomatous processes (fungus, sarcoid, syphillis, early cat-scratch disease, etc)– won’t have granulomas in follicles

  10. Case 3 • Enlarged inguinal lymph node in a 47-year old male soldier who recently returned from a tour in Korea. At home he has dogs, cats, rabbits, and parrots.

  11. Diagnosis • Cat-Scratch Disease

  12. Key Points • Early- non-necrotizing granulomas • Late- suppurative granulomas- peripheral palisaded epithelioid histocytes and central microabcess with neutrophils • Causative agent- Bartonella henselae seen on Warthin-Starry stain- clumps of rod-shaped to curved bacilli

  13. DDx • Lymphogranuloma venereum • Tularemia • Yersinia pseudotuberculosis • Suppurative lymphadenitis caused by bacteria

  14. Case 4 • 13-year old African American male with cervical adenopathy for 1 month.

  15. Diagnosis • Sinus Histiocytosis with Massive Lymphadenopathy (Rosai-Dorfman Disease)

  16. Key Points • Sinuses markedly dilated by histiocytes with scattered leukocytes • Histiocytes are large and have abundant cytoplasm • Emperipolesis by lymphs or plasma cells • Intersinusoidal tissue with mature lymphs and plasma cells • Germinal centers absent or inconspicuous

  17. Key Points (cont.) • Capsular and pericapsular fibrosis • Usually young (< 20 y/o) • Male > Female, Af Amer > white • Cervical adenopathy most common, usually bilateral and massive • Can occur in extranodal sites • Anemia, leukocytosis, polyclonal gammopathy

  18. Key Point (cont) • Clinical course is protracted with slow progression of adenopathy and persistence for months to years with gradual resolution • Surgery, chemoRx and XRT have been tried with mixed results

  19. DDx • Sinus histiocytosis • Malignant histiocytosis • Infection-associated hemophagocytic syndrome • Langerhans cell histiocytosis • Metastatic carcinoma and melanoma • Infections with increased macrophages (eg., MAI)

  20. Case 5 • 60-year old man with a left parotid mass. FNA was consistent with a benign process.

  21. Diagnosis • Kimura’s Disease

  22. Key Points • Preserved nodal architecture with follicular hyperplasia • Eosinophils infiltrating sinuses and interfollicular area with occasional eosinophilic abscesses • Increased postcapillary venules in interfollicular areas

  23. Key Points (continued) • Usually interstitial deposition of proteinaceous material between germinal center cells • Often IgE staining within germinal center • Occurs primarily in Asian ethnic group • Young to middle age; male > female • Usually peripheral eosinophilia and increased serum IgE

  24. Key Points (cont) • Usually resolves spontaneously • Can treat with corticosteroids, cetirizine, surgical resection, or XRT

  25. DDx • Angiolymphoid hyperplasia with eosinophilia • Hodgkin lymphoma • Eosinophilic granuloma • Drug reaction • Parasitic lymphadenitis

  26. Bonus Case • 30-year old HIV-positive man with fever and right groin pain and mass. He has 3 cats at home.

  27. Diagnosis • Bacillary Angiomatosis

  28. Key Point • Multiple coalescent nodules of proliferating vessels haphazardly scattered in the parenchyma • Vessels barely canalized and lined by plump endothelial cells • Abundant eosinophilic to amphophilic, amorphous or granular interstitial material formed by aggregated bacilli

  29. Key Points (cont) • Neutrophils and extravasated RBCs frequent • Caused by Bartonella henselae- seen on W-S stain (clumps of bacilli) • See in HIV patients, esp when CD4 < 100 • Commonly involves LN, skin, spleen • Usually shows excellent response to antibiotics (erythromycin, doxycycline)

  30. DDx • Kaposi’s sarcoma • Angiolymphoid hyperplasia with eosinophilia • Epithelioid hemangioendothelioma • Angiosarcoma

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