Description of five cases of bartonellosis with fever and atypical clinical presentations in kidney transplant recipients : thrombotic microangiopathies, recurrent haemophagocytosis and immune reconstitution syndrome after treatment. The diagnosis, the pathological lesions, and treatments are described. Bartonellosis must be researched in solid organ transplant recipients with fever of undetermined origin.
Prenatal diagnosis is fundamental in the therapeutic approach to this rare lesion but remains difficult because the findings are non specific and the generally late development of the tumor.
Lymph node involvement in cat scratch disease is characterized by a granulomatous lymphadenitis with micro-abscesses. Recently, it has been shown that the possible aetiological agent is a micro-organism which stains with some silver stains. In this study 60 lymph nodes were studied from 60 patients, using a modified Dieterlé's stain. In 40 cases (66%) rod-shaped bacilli with rounded extremities were observed. They were negative both with the Gram and Ziehl-Neelsen stains. Since such micro-organisms were demonstrated in the majority of the nodes examined, it can be concluded that silver stains are appropriate for the diagnosis of this condition.
Background
Lyme borreliosis is the most prevalent arthropod-borne infection in the Northern Hemisphere. In Europe, Borrelia afzelii is predominantly involved in cutaneous manifestations, Borrelia garinii and Borrelia bavariensis in neurological manifestations, and Borrelia burgdorferi sensu stricto in articular ones. Liver impairement is not classical in Lyme borreliosis. Diagnosis is currently mainly based on serological testing, and is challenging in immunocompromised patients.
Case presentation
We report the first case of B. garinii infection revealed by liver involvement in an immunocompromised man. A 73-year-old man with marginal zone lymphoma, treated with bendamustine and rituximab, developed intermittent fever and inflammatory syndrome. Microbial investigations were all negative and FDG-PET showed complete remission of the lymphoma. Three months later, liver biopsy was performed and histology revealed spirochetes-like bacteria. Microbial diagnosis was performed by 16S rDNA sequencing, flagellin (flaB) gene sequencing and multi-locus sequence typing and identified B. garinii. The patient recovered successfully after a three weeks course of antibiotics. Diagnosis was challenging because Borrelia hepatic involvement is unusual and no erythema migrans nor tick bite were notified.
Conclusion
This case highlights that unexplained fever and inflammatory syndrome in immunocompromised patients warrants specific investigations to identify bacteria such as spirochetes.
Inflammatory pseudotumor (IPT) is a benign tumor-like lesion of unknown cause and is originally described in the lung and orbit, but it has recently been reported throughout the body and only a small number of people [1,3,6]. We presented a rare case of costo-vertebral inflammatory pseudotumor with epidural invasion presenting with progressive cervico-brachial pain. There were no signs of myelopathy.
Case PresentationA 50-year-old male had a two month history of left cervicobrachial pain, with progressive weakness in left upper limb. The patient signed an informed written consent form before participation. The neurologic examination showed brachial monoparesis predominantly in distal left without pyramidal signs. Magnetic resonance imaging (MRI) showed hypointense lesion in both T1-and T2-weighed images (Figures 1,2) with intense contrast enhancement at the left costo-vertebral gutter with epidural extension through the lateral foramen, causing a compression on the spinal cord from C7 to D3 (Figure 3). The thoraco-abdominal CT scan did not show other lesions. A CT scan-guided biopsy through posterior-lateral approach was performed. The histological examination revealed that the lesion was made of dense collagen with fibrous background, associating fibroblastic or myofibroblastic cells having a clarified ovoid nuclei and inflammatory cells grouped into small clusters formed mainly of plasma cells and lymphocytes, and the lesion was richly vascularized. No necrosis was observed. The antiactin smooth muscle antibody marked diffuse myofibroblasts that are H-caldesmone negative, the ALK was positive and the anti-cytokeratin AE1/AE3 antibody was negative excluding the possibility of an epithelial tumor. Hence, the diagnosis of an inflammatory pseudotumor was made.Treatment started by steroids (1mg/kg/d) with adjuvant radiotherapy. There was a rapid recovery in his neurological functions, and there was a complete resolution of the lesion on control MRI after three years. There was no evidence of pulmonary or other lesions.
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