Contributed by Joel F Gradowski, MD and William Pasculle, ScD.
The patient was a 57-year-old male diabetic who was discovered to have a persistent leukocytosis. His past medical history was remarkable for recently diagnosed diabetes mellitus and a 40 pack-year history of smoking cigarettes. A hematologist was following the patient. His white blood cell count increased from 16,700/ul to 63,000/ul during a period of 8 months. The patient underwent two bone marrow biopsies twice in a 2-month period, which were inconclusive for malignancy. Both bone marrow biopsies were negative for bcr/abl gene mutation. He denied any "B" symptoms. The patient was reported to have been treated with hydroxyurea.
The patient presented to the emergency department at UPMC several weeks later with a chief complaint of chest pain. He was afebrile on admission. Further workup revealed that the patient was in atrial fibrillation. A CT scan was performed as part of a workup for pulmonary embolus. The CT revealed extensive mediastinal lymphadenopathy (up to 3.3 cm), compression of the superior vena cava, compression of bilateral pulmonary arteries, and multiple lung nodules. Upon further questioning, the patient admitted to a 50-pound weight loss over the last two months as well as night sweats.
|Admission laboratory data|
The patient was given Amiodarone for atrial fibrillation and Zosyn for presumed bacterial pneumonia. The patient received two doses of radiation therapy to relieve the superior vena cava syndrome. Five days after admission the patient underwent a surgical excision of a right cervical lymph node.
Grossly, the lymph node was largely necrotic. A repeat bone marrow biopsy was performed on 14th day of admission. Histologic sections revealed: The lymph node had very little preserved architecture and was mostly composed of necrotic debris with some neutrophils. The bone marrow had scattered poorly formed granulomas.
AFB stains on lymph node and bone marrow revealed acid-fast organisms in lymph node and bone marrow. Cultures were planted.
Culture results: Yellow colonies on LJ slant after exposure to light, cream-colored colonies on LJ slant in dark. Photochromogenic mycobacteria suspected.
Mycobacterium tuberculosis DNA probe was negative. Mycobacterium gordonae probe negative. Mycobacterium kansasii probe sent to Cleveland Clinic.