Family History บิดามารดามีอาชีพทำไร่ สุขภาพแข็งแรงดี ไม่ มีอาการไอเรื้อรัง เคยทำเอ็กซเรย์ปอด ผล ปรกติ ไม่มีประวัติใกล้ชิดกับผู้ป่วยวัณโรค Physical Examination GA: A Thai boy, active, good conscious, not pale, no jaundice HEENT: pharynx and tonsils-normal marked dental caries tympanic membrane intact
- Left anterior cervical lymph node enlargement ~ 5 cm 1 node, firm, not tender -2 adjacent lymph nodes enlargement ~ 1 cm, firm, not tender
Physical Examination Heart: normal S1 S2 Lungs: normal breath sounds Abdomen: soft, not tender, liver & spleen not palpable, no abnormal mass Skin: hyperpigmented patch on forearms, back and buttock diameter ~ 5-10 cm.
Investigation CBC: Hct 37.8%WBC 11,300/cumm N 38% L 38% B 3% M 3% E 18% Platelet 245,000/cumm ESR 18 mm/hr U/A: sp.gr. 1.025 pH 6.0 protein negative, sugar negative, no WBC and RBC
Problem List Isolated Left anterior cervical lymph node enlargement 5 cm in diameter Not response to antituberculous drugs Eosinophilia
What could be the most likely diagnosis and the next step of management? A.Mycobacterium tuberculosis B. Atypical Mycobacterium C.Melioidosis D. Cat scratch disease E. Toxoplasmosis
Lymph node biopsy Section reveals fibromuscular tissue consisting of dense lymphoid aggregates containing prominent germinal centers. Thin-walled blood vessels and dense infiltrates of eosinophils forming eosinophilic abscesses are present adjacent to the lymphoid aggregates. No epithelioid endothelial cell is seen. Neither granuloma nor malignancy is noted.
Localized melioidosis (primary skin infection) Treatment – Drainage – Single drug-co-trimoxazole, doxycyclin – At least 3-4 weeks
Progression Prednisolone was tapered to 1 tablet tid and then 1 tablet bid Co-trimoxazole and doxycyclin were given At the next 2 months visit, the infected wound was much improved and the neck mass was not palpable Then prednisolone was tapered to 1 tablet OD, only co-trimoxazole antibiotic was continued
Progression Last visit (27-07-04) the neck mass recurred, the wound healed prednisolone was increased to 1 tablet bid and continue co-trimoxazole The patient next appointment will be 25- 08-04