Clinical History: 5 year-old male patient who 2 years ago presented with a tumor formation in the neck area.  No pathology was revealed in the oral cavity.  There was no history of contact with TB infection.  Anti-TB vaccination (BCG) was performed in maternity home, tuberculin test was negative.  However, anti-tuberculosis treatment of 14 days duration was performed.  The formation disappeared, but it reappeared in the same area during last spring 2004.  This tumor was not painful and changes on lymph nodes in other regions were not observed. The patient was placed in a national center of Tuberculosis from July 19^th, 2004 till July 28^th, 2004 with diagnosis of tuberculosis of peripheral lymph nodes. A biopsy of the neck’s lymph node was performed.

Laboratory

Peripheral Blood Counts:

March 24th, 2004	July 13th, 2004	August 23rd, 2004
Hemoglobin – 130.078 g/L Erythrocytes – 4.2 Color index – 0.93 Trombocytes – 70% Leukocytes – 8.9 x1000/mm3 Stab neutrophils – 6.0% Mature neutrophils – 47.0% Eosinophiles – 1.0% Lymphocytes – 32.5% Monocytes – 13.5% Erythrocyte Sedimentation Rate – 30 mm per hour	Hemoglobin – 120 g/L Erythrocytes – 4.3 Color index – 0.84 Trombocytes – 70% Leukocytes – 7.9 x1000/mm3 Stab neutrophils – 6.0% Mature neutrophils – 69.0% Eosinophiles – 2.0% Lymphocytes – 18.0% Monocytes – 9.0% Erythrocyte Sedimentation Rate – 40 mm per hour	Hemoglobin – 120.07 g/L Erythrocytes – 4.1 Color index – 0.88 Trombocytes – 70% Leukocytes – 7.7 x1000/mm3 Stab neutrophils – 3.5% Mature neutrophils – 55.0% Eosinophiles – 1.5% Lymphocytes – 27.5% Monocytes – 12.5% Erythrocyte Sedimentation Rate – 55 mm per hour

 

First histological diagnosis:  Biopsy from neck's lymph node. The lymphoid histological structure is partially obliterated. The large follicular centers are hyperplastic. The lymphocytic population is represented mainly by middle-sized lymphocytes and eosinophiles. Also observed are some Hodgkin’s type cells with light nuclei (nucleolus) and very rarely (individual) Sternberg like cells.  In accordance with this histology the initial stage of lymphogranulomatosis (so called lymphogranulomatosis with lymphoid-cellular predominance) can be suspected. This supposition could be proved by immunohistochemical investigation, particularly by usage of marker of Hodgkin’s and Sternberg cells – CD15 and also monoclonal markers CD43, CD45, CD20, Bcl-2, Ki-67.  Moreover for the purpose to rule out lymphadenopaties caused by viral infections virology investigation must be performed.

Serologic investigation for viral infections

CMV – IgM negative; IgG positive (1 IU/ml, positive >0,5 IU/ml)

Clam. Tr. – IgM negative; IgG negative

EBV – IgM negative; IgG positive

Second histologic diagnosis:  Biopsy from neck's lymph node.  The lymphoid histological structure is partially obliterated.  The large follicular centers are hyperplastic. In some preparations at the periphery of lymph node micro abscessed areas are observed. Cellular population is mainly presented by middle sized lymphocytes, among them are revealed  groups of eosinophiles and individual Hodgkin’s type cells with light nuclei (nucleolus) and very rarely (individual) Sternberg like cells.  Mitosis are observed. Capillaries with high endothelial cells are very often.

Immunohistochemical investigation:

CD-20 – Cells of reproductive centers of follicles and the little amount of interfollicular lymphocytes are positive.

CD-43 – 90% of interfollicular cells are positive.

CD-15 - 90% of cells (activated T and B lymphocytes) and also Hodgkin’s type and Sternberg like cells are positive.

CD-30 – 5% of cells which are located among lymphoid cells like diffuse separate cells.

CD-68 – Plural macrophages, which are made up 20% of cellular population, are positive.

Vimentin – negative.

S-100 – Dendritic cells, which are scattered as an individual cells in lymphoid tissue and made up 10% of total cellular quantity are positive.

Bcl-2 – Negative.

Conclusion. In accordance with the histological appearance and results of immunohistochemical investigation on the background of reactive changes in lymph node it is presented cellular population those qualitative and phenotypic contents does not ruled out the presence of initial phase of lymphogranulomatosis (lymphogranulomatosis with lymphoid-cellular predominance). The reactive changes of lymph node could be stipulated by the EBV and CMV infection. It should be also taken into account, that mentioned infections could be raised as the opportunistic infections in immune deficient patients (on the background of immunodeficiency developed as the result of lymphogranulomatosis initial stage).

Comments:  Please, write Your opinion and the suggestions about the further treatment strategy of this case to Eka Kldiashvili, Ph.D. kldiashvili@georgia.telepathology.org, Georgian Telemedicine Union (Association), Tbilisi, Georgia.