Right Axillary Mass
Article Outline
[Ann Emerg Med. 2010;56:600.]
A 47-year-old man without systemic disease presented to the emergency department with fever and shaking chills for 3 days. A painful axillary swelling mass progressively enlarged within a few days. Physical examination revealed an erythematous, tender, nonfluctuant, enlarged lymph node measuring about 2×2 cm over his right axillary area (Figure 1). Routine laboratory tests were unremarkable except for mild leukocytosis, with a WBC count of 11,600/uL. Blood cultures and viral serologic test results were all negative. Sonography of right axilla confirmed a soft tissue mass, rather than an enlarged lymph node (Figure 2). Computed tomography of the chest was arranged and disclosed a right axillary, well-enhanced, soft tissue mass measuring 4.0×3.6 cm (Figure 3). Soft tissue biopsy was obtained, and histopathologic reports revealed necrotizing granulomata formation made up of central microabscesses with polymorphonuclear granulocyte infiltration and surrounded by a peripheral rim of palisaded epithelioid cells.
Figure 1.
An erythematous, tender, nonfluctuant, enlarged lymph node measuring about 2×2 cm over the right axillary area.
Figure 2.
Ultrasonography of the right axilla, showing a soft tissue mass, rather than an enlarged lymph node (arrow).
Figure 3.
Computed tomography of the chest with enhancement revealed a well-enhanced, lobular-margined, soft tissue mass over the right axillary region, measuring 4.0×3.6 cm (arrow).
Used with permission of Kai-Yuan Wang, MD, Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan.
Diagnosis
Cat scratch disease. Warthin-Starry silver stain highlighted the small, curved, Gram-negative bacilli in these granulomas from the biopsy of lymph node, which, along with the history of recent contact with a cat, confirmed the diagnosis of cat scratch disease. Cat scratch disease was first described by Henri Parinaud in French medical literature around 1889. Dr. Robert Debre recognized the cat as a vector of this disorder and named it cat scratch disease in 1931. Cat scratch disease is a self-limiting infectious disease caused by infection with Bartonella henselae, which affects both children and adults but is principally a pediatric disease.1 It is characterized by painful regional lymphadenopathy after the cat scratch (primarily scratches from kittens). Cat scratch disease may lead to some rare complications, including hepatosplenic granuloma, splenic abscesses, transverse myelitis encephalitis, osteomyelitis, neuroretinitis, and endocarditis. Diagnosis is commonly made by serologic testing for antibody of B henselae. Furthermore, histopathologic features are positive under Brown-Hopp tissue Gram's stain, and Warthin-Starry silver stain.2 The disease is typically self-limiting and will spontaneously resolve in 2 to 3 months. Antibiotics may be indicated for symptomatic patients with systemic involvements and for immunocompromised patients. Trimethoprim sulfamethoxazole, gentamycin, ciprofloxacin, and rifampin are drugs of choice.
References
For the diagnosis and teaching points, see page 622.
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PII: S0196-0644(09)01737-5
doi:10.1016/j.annemergmed.2009.11.012
© 2009 Published by Elsevier Inc.
