Hoarseness, cough and cervical lymphadenopathy

A. J. Turk, T. Brack, C. Alfaré, A. Gaspert, E. W. Russi

European Respiratory Journal 2005 26: 174-177; DOI: 10.1183/09031936.05.00137004

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CASE HISTORY

A 43-yr-old native Brazilian female complained of a sore throat, recent onset of hoarseness, progressive pain and bilateral swelling of the neck during the past 6 months, when she presented at the University Hospital of Zurich (Zurich, Switzerland) for the first time. The patient had moved to Switzerland 5 yrs before, had been a heavy smoker for the past 20 yrs and coughed chronically. She reported a short episode of minor haemoptysis 2 yrs previously that had ceased spontaneously. The patient suffered no fever or night sweats, but had lost 2 kg of weight during the past 2 months, despite a normal appetite. Five months previously, she had spent 3 months in a town south of the capital Brasilia, where she was treated with sulphamethoxazole and trimethoprim for pneumonia. After a transient recovery, the cough, sore throat and cervical swelling reappeared.

The patient’s past medical history was unremarkable for severe diseases or surgery, other than a bilateral silicon breast implant. A year before, the patient stopped taking four different drugs to lose weight, containing substances such as benzodiazepines, fluoxetine, metoclopramide and diethyl-propione, a stimulant that is commonly used as an appetite suppressant in Brazil.

The clinical examination was remarkable for enlarged, painful cervical lymph nodes and a few bibasilar rales. The patient had bilateral silicon breast implants. Her temperature was normal, white blood cell count was 10.09×10⁻³·μL⁻¹ (without left shift), C-reactive protein was 42 mg·L⁻¹ (normal: <5 mg·L⁻¹) and HIV antibodies were negative. The chest radiograph (fig. 1⇓) taken 3 months previously in Brazil showed dense bilateral alveolar infiltrates, predominantly in the mid-zone of the lungs. A recent computed tomography (CT) scan is shown in figure 2⇓. Fine-needle aspiration of a cervical lymph node demonstrated necrotising epitheloid granulomas without acid-fast bacilli, and the culture of the aspirate did not grow mycobacteria. Bronchoscopy (fig. 3⇓) with bronchoalveolar lavage (BAL) and transbronchial biopsies were performed (figs 4⇓ and 5⇓).

Fig. 1—

Chest radiograph taken 3 months prior to the current presentation.

Fig. 2—

Thin-section computed tomography at the level of the lower lobes.

Fig. 3—

View of the larynx and vocal cords during bronchoscopy.

Fig. 4—

Transbronchial lung biopsy with a) Elastica van Gieson stain, and b) haematoxylin and eosin stain. Scale bars = 50μm (a) and 200 μm (b).

Fig. 5—

Transbronchial lung biopsy (Grocott’s hexamine-silver stain). Scale bar = 20 μm.

BEFORE TURNING THE PAGE, INTERPRET THE COMPUTED TOMOGRAPHY SCAN, THE BRONCHOSCOPIC VIEW OF THE LARYNX AND THE LUNG BIOPSY FINDINGS AND SUGGEST A DIAGNOSIS.

INTERPRETATION

Chest radiograph

The chest radiograph shows dense bilateral alveolar infiltrates, predominantly in the mid-zone of the lungs (fig. 1⇑).

Computed tomography

The CT scan reveals small, peripheral and spiculated consolidations with signs of architectural distortion. Some consolidations are surrounded by confluating air-space nodules and subtle areas of ground-glass opacities (fig. 2⇑).

Bronchoscopy

Bronchoscopy revealed an inflamed, enlarged, oedematous larynx with a cobblestone-like mucosa (fig. 3⇑) and a purulent bronchitis. BAL was remarkable for intracellular fungal spores in macrophages.

Pathology

The transbronchial biopsies demonstrated a granulomatous and interstitial inflammation with macrophages and multinucleated giant cells containing fungal spores (figs 4⇑ and 5⇑).

Culture of BAL

The fungal cultures grew Paracoccidioides brasiliensis.

Diagnosis: Paracoccidiomycosis with involvement of the cervical lymph nodes, larynx and lung.

Clinical course

The patient was treated with 2×100 mg·day⁻¹ of itraconazole over 6 months, and promptly recovered from the cough and the hoarseness. The cervical lymphadenopathy also disappeared. A CT scan at follow-up was unremarkable except for some interstitial scarring. Retrospectively, fungal spores could be identified in the Grocott’s hexamine-silver stain of the fine-needle aspirate of the cervical lymph node.

DISCUSSION

Paracoccidiomycosis, also known as South American blastomycosis, is considered a primary systemic mycosis in contrast to the opportunistic mycoses that only affect immunocompromised patients. Other primary systemic mycoses are histoplasmosis, coccidiomycosis and North American blastomycosis. Their common habitat is the soil. The spores are inhaled and cause a primary pulmonary mycosis 1. Primary systemic mycoses are also called endemic mycoses because they occur only in certain geographical regions. Paracoccidiomycosis occurs exclusively in South America, where South Mexico (23°N latitude) and Argentina (34. 5°S latitude) build the northern and southern border of the endemic area, respectively. Approximately 60% of the cases occur in Brazil, while fewer cases are seen in Colombia, Venezuela, Argentina and Peru. Areas with the highest incidences are subtropical rainforests and damp mountain forests. The disease does not occur in hot, dry areas or in rainforests around the equator where the temperature rises above 25°C.

Paracoccidiomycosis is not transmitted among humans. Most patients with paracoccidiomycosis are male agricultural workers. The outbreak of the disease is favoured by malnutrition and alcoholism. Tuberculosis (TB) occurs as a co-infection in 12% of the cases 2. After inhalation of the fungal spores, there is often an asymptomatic or subclinical primary pulmonary paracoccidiomycosis that disappears without leaving any radiological residuals, while subclinical histoplasmosis often causes characteristic residuals, such as pulmonary granulomas and calcified mediastinal lymphomas. Many years after subclinical paracoccidiomycosis, the disease can be reactivated. In a series of patients who had immigrated to Spain, there was a mean reported latency of 14 yrs, ranging from 4 months to 60 yrs 3.

As demonstrated in the current patient, cervical and submandibular lymphadenopathy, which may be complicated by cutaneous or mucocutaneous fistulae, frequently accompany pulmonary disease. Pharyngeal ulcers and laryngitis causing throat pain and hoarseness, similar to that experienced by the present patient, are other common manifestations of the disease. In severe cases, the granulomatous laryngitis may even be mistaken for cancer 4.

Radiological manifestation of pulmonary disease is variable and ranges from alveolar to reticulo-nodular interstitial infiltrates. Frequently, perihilar butterfly-shaped opacities, cavitary lesions and traction bronchiectasies may be noted 5. Since radiographic presentation is highly variable, paracoccidiomycosis may mimic TB, sarcoidosis, Wegener’s granulomatosis or carcinoma and other systemic mycoses. Biopsies are often diagnostic because Grocott’s hexamine-silver stains paracoccidioides, which can then easily be identified within epitheloid granulomas. Fungal cultures finally confirm the diagnosis. Serological tests are available, but they are time consuming, expensive and the antibody production can be suppressed in immunocompromised patients where the detection of the specific antigen may be more helpful. Serial antibody detection can be used to document the success of the antifungal therapy.

Left untreated, paracoccidiomycosis has a high mortality rate. In 1940, sulphonamides were used for the first time as a therapy that was successful in ∼60% of patients 2. This was a 3-yr therapy, which often resulted in a relapse when the treatment was terminated precociously. Sensitivity of paracoccidioides to sulphonamides may also explain the transitory recovery of the patient during her 2-week treatment with sulphamethoxazole in Brazil. Therapy with azole-derived antifungals increased the rate of success from 60 to 90%. The current recommendation is a therapy with 100 mg itraconazole b.i.d. over 6 months. With this regimen, a success rate of 93% has been reported 2. An alternative treatment consists of ketoconazole 400 mg·day⁻¹ over 6–18 months. Even after successful elimination of the fungus, affected organs may remain permanently damaged by fibrosis and scarring. Laryngo-tracheal stenoses and scarring of the lung are well-known, long-term sequelae.

Physicians in nonendemic areas should be aware of paracoccidiomycosis, since more cases are expected with increasing migration and international travel. Symptoms such as hoarseness, pharyngeal pain with mucosal ulcerations, cervical lymphadenopathy and chronic cough in patients with a history of travelling in South America should raise suspicion for this disease that may be reactivated after years of latent infection.

• Received November 30, 2004.
• highwire.org/Journal” hwp:start=”2005-02-18″>Accepted February 18, 2005.

References

1. ↵

   Kayser FH, Bienz KA, Eckert J, Zinkernagel RM. Primäre Mykosen [Primary Mycosis]. In: Medizinische Mikrobiologie. 9. Auflage [Medical Microbiology. 9th Edn]. Stuttgart, Georg Thieme Verlag, 2001; pp. 372–376

2. ↵

   Taborda AB, Arechavala AI. Paracoccidioidomycosis. In: Sarosi GA, Davies SF, eds. Fungal Diseases of the Lung. 3rd Edn. Philadelphia, Lippincott Williams & Wilkins, 2000; pp. 79–89

3. ↵

   Ajello L, Polonelli L. Imported paracoccidioidomycosis: a public health problem in non-endemic areas. Eur J Epidemiol 1985;1:160–165.

4. ↵

   Sant’Anna GD, Mauri M, Arrarte JL, Camargo H Jr. Laryngeal manifestations of paracoccidioidomycosis (South American blastomycosis). Arch Otolaryngol Head Neck Surg 1999;125:1375–1378.

5. ↵

   Bethlem EP, Capone D, Maranhao B, Carvalho CRR, Wanke B. Paracoccidioidomycosis. Curr Opin Pulm Med 1999;5:319–325.

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Symptoms of acute lymphoblastic leukaemia (ALL)

Symptoms of ALL can be similar to those caused by other illnesses. The symptoms are caused by too many abnormal white blood cells and not enough normal white cells, red cells and platelets. 

Symptoms of ALL might include one or more of the following:

• feeling weak or tired
• flu-like symptoms
• a high temperature (fever)
• picking up or not being able to shake off infections such as coughs and colds
• bruising and bleeding easily
• weight loss
• swelling of your lymph nodes
• pain in your bones or joints
• breathlessness
• feeling full in your tummy (abdomen)
• looking pale or washed out

General weakness

You might feel weaker than normal.  

Feeling tired (fatigue)

You might feel more tired than normal, even if you’re getting a good nights sleep.

High temperature (fever)

You might have a high temperature or feel feverish.

Frequent infections

You might pick up infections such as coughs and colds easily. Or you might find that the infections last a long time and are difficult to shake off.

This is because you don’t have enough healthy white blood cells to fight bacteria or viruses.

Bruising or bleeding easily

You might have:

• nosebleeds
• bleeding gums when you clean your teeth
• very heavy periods
• small dark red spots on your skin
• blood in your wee (urine) or poo (stool)

You might find you are bruising more easily than normal.

Weight loss

You might lose weight even if you haven’t changed your diet.

Swollen lymph nodes

Your lymph nodes (glands) might feel swollen when you touch them. You have lymph nodes in lots of places in your body. They might feel swollen in:

• your neck
• under your armpit
• in your groin

Pain in your bones or joints

You might feel pain in your bones or joints. This might be a dull ache or more of a stabbing pain. It might be worse at different times of the day.

Too many abnormal white blood cells collecting in the bones, joints or lymph nodes may cause pain and swelling.

Feeling short of breath (breathlessness)

You might feel breathless when doing your normal day to day activities or from climbing a short flight of stairs. This could be because you do not have enough red blood cells. 

Feeling full in your tummy (abdomen)

You might have a feeling of fullness or discomfort in your tummy (abdomen). This can happen if your liver or spleen are swollen.

Pale skin

You might look paler or more ‘washed out’ than normal. 

Other symptoms

A type of leukaemia called T cell ALL can cause swollen lymph nodes in the centre of your chest. It might make the thymus gland in your upper chest bigger. The swollen nodes or thymus gland may press on the windpipe, causing breathlessness and coughing.

They can also press on the veins carrying blood from the head. This causes pressure in the blood vessels and makes the face, neck and arms swell and go red. This is called superior vena cava obstruction (SVCO).

Go to the accident and emergency (A&E) department at your nearest hospital if you have any of these symptoms. It can be a medical emergency.

When to see your doctor

You should get any of these symptoms checked by your GP. But remember, they can all be caused by other medical conditions. Most people with these symptoms don’t have leukaemia.

• Suspected cancer: recognition and referral
  National Institute for Health and Care Excellence (NICE), June 2015. Last Updated January 2021

• Scottish Referral Guidelines for Suspected Cancer
  NHS Scotland, Last Updated October 2020

• Hoffbrand’s Essential Haematology (8th Edition)
  AV Hoffbrand and D A Steensma
  Wiley Blackwell, 2020

• Cancer: Principles and Practice of Oncology (11th edition)
  V T De Vita, T S Lawrence and S A Rosenberg
  Wolters Kluwer, 2019

• Acute lymphoblastic leukaemia
  F Malard and M Mohty
  The Lancet, 2020. Volume 395, Issue 10230, Pages 1146 to 1162

• The information on this page is based on literature searches and specialist checking. We used many references and there are too many to list here. Please contact [email protected] with details of the particular issue you are interested in if you need additional references for this information.

Last reviewed: 

18 May 2021

Next review due: 

18 May 2024

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causes, symptoms, signs, diagnosis, treatment, diet

Causes

Classification

Symptoms

Complications

Diagnosis

Treatment

Mesadenitis – inflammation of the lymph nodes located in the mesentery of the small intestine. The mesentery is the organ by which the human intestine is attached to the posterior wall of the peritoneum. It is a double fold. In addition to lymphatic and blood vessels, nerve plexuses also pass here. Also, the mesentery unites all intestinal loops into a single whole and prevents them from twisting among themselves.

Intestinal mesadenitis develops for various reasons, manifested by severe abdominal pain (they can appear in any part of it), fever, nausea and diarrhea. Laparoscopy is used for diagnosis, and surgeons in a hospital are engaged in treatment.

There are approximately 600 lymph nodes in the mesentery, which provide protection against infection and prevent it from spreading to the entire abdomen. The incidence of mesadenitis does not exceed 12% among all surgical pathologies. Mesadenitis often develops in children, while girls with an asthenic physique, underweight or who have passed into adolescence get sick more often. The seasonality of the disease is autumn-winter, when the incidence of acute respiratory viral infections increases.

Causes and triggers

Mesadenitis of the abdominal cavity is a disease that develops a second time, with an already existing inflammatory focus. It can be located in the appendix, intestines, bronchi or in any other organ of the human body, and the causative agent of the disease enters the lymph nodes through the flow of lymph, blood, being absorbed through the intestines. After the penetration of the pathogen into the lymph nodes of the mesentery, an acute inflammatory process begins in them, accompanied by vivid symptoms.

Causes of mesadenitis are:

1. Viruses. Inflammation in the mesentery develops secondarily and is often the result of infection with adenovirus. The diseases that provoke it are tonsillitis, pharyngitis, cystitis, conjunctivitis. This should also include enterovirus, mononucleosis, Epstein-Barr virus.
2. bacteria. The disease can begin under the influence of opportunistic or pathogenic bacteria that live in the intestines, nasopharynx. Inflammation of the mesentery is also noted as one of the manifestations of tuberculosis of any localization. But most often the culprits of inflammation are staphylococci, streptococci and Escherichia coli, which, under favorable conditions, turn from opportunistic pathogens into the cause of the inflammatory process.

Mesadenitis in adults is quite rare. The main provoking factor is the lack of treatment of viral diseases, influenza, colds, SARS. In children, precipitating factors include imperfections in the immune system, food poisoning, colds, and intestinal disorders, often associated with malnutrition or strict diets during adolescence.

Classification

Modern surgery divides mesadenitis into acute and chronic forms, in which the manifestations and complaints presented by the patient differ.

Acute mesadenitis is simple and destructive. In the first case, there are acute cramping pains in the abdomen with a duration of attacks from 10 minutes to several hours. This form is detected in 80% of cases. In the second case, the pain is permanent, the temperature rises.

Chronic mesadenitis is manifested by periods of exacerbation and remission. During exacerbation, the symptoms are very pronounced, and during the period of subsidence, the patient has practically no complaints or they are slightly expressed and do not cause much discomfort. The chronic form occurs more often in those who have an unsanitized focus of inflammation in the body or are underweight.

Mesadenitis also happens:

• non-specific, simple or purulent;
• pseudotuberculous, which is especially difficult and can cause death;
• tuberculosis, with a long chronic course, periods of exacerbation and remission – this form of the disease is also called specific.

In the ICD, the mesadenitis code will be I88.0, the correct name of the disease is also given there – mesenteric lymphadenitis.

Symptoms

Symptoms of the acute form of mesadenitis appear suddenly and progress rapidly. The patient complains of long-term pain, cramping in the navel and upper abdomen. Often it is impossible to show the exact location, and the person says that he literally hurts all over his stomach.

Then severe pain becomes dull and moderate, but it becomes worse every time the patient tries to change position of the body, coughs, sneezes or makes awkward movements. The temperature rises, tachycardia appears, the respiratory rate increases. Nausea gradually appears, vomiting, diarrhea, loss of appetite, severe prolonged hiccups are possible. Dyspeptic disorders may be accompanied by cough, runny nose, sore throat, exacerbation of herpes. However, the general condition suffers slightly.

When a purulent focus appears, the general state of health deteriorates, the pain intensifies, signs of intoxication appear. This requires immediate medical attention.

Signs of chronic mesadenitis disturb the patient from time to time, the attack can last for several days, after which it usually disappears on its own. Symptoms are not clearly expressed, there are no specific signs of the disease. The pains are mild and do not have a clear localization. Periodically, nausea occurs, and diarrhea is replaced by constipation.

Tuberculous mesadenitis deserves special attention. It is characterized by severe sweating, weakness, pale skin, weight loss, an increase in almost all lymph nodes, the temperature rises to 38 degrees and can remain in this position for a long time. Very rarely, mesenteritis occurs without any symptoms.

Complications

Despite the fact that the disease is well treated with conservative methods, a number of serious complications can develop in a patient with a late visit to the doctor. These include the spread of purulent processes to the lymph nodes and the abdominal cavity with the development of abscesses, peritonitis, generalized lymphadenitis. Sepsis also becomes a formidable complication, and later adhesions and intestinal obstruction may develop.

Diagnostics

A gastroenterologist or surgeon will be able to make a correct diagnosis and prescribe the correct treatment. Diagnosis of mesadenitis includes a doctor’s examination, laboratory tests, MRI of the abdominal cavity. Mesadenitis on ultrasound will look like dense and enlarged lymph nodes.

If there are doubts about the diagnosis, as well as to exclude appendicitis and other similar inflammatory symptoms, a diagnostic laparoscopy is performed. So you can see the affected lymph nodes, find out their number, size, location, perform a detailed examination of all neighboring organs. For accurate diagnosis, laparoscopy often takes material for histology.

Treatment

Antibiotics are prescribed for uncomplicated mesadenitis. The doctor should select the drug, but cephalosporin drugs are usually used. With tuberculous etiology, treatment of mesadenitis is performed in an anti-tuberculosis hospital with all precautions. To combat intoxication, solutions are administered intravenously. To combat diarrhea, constipation and dyspeptic symptoms, diet therapy is used.

Diet for mesadenitis is prescribed for the entire period of treatment. Low-fat meats and fish, vegetable broth soups, crackers (but not fresh wheat bread), steamed omelettes, sour-milk drinks, cereals, baked or stewed vegetables are allowed. All fatty and fried foods, rich broths, legumes, any seasonings, ketchup, mayonnaise, coffee, chocolate and cocoa are completely excluded.

If the abscess is purulent, surgery may be required to open and drain the abscess. Physiotherapy includes UHF, magnetotherapy, but no warming methods are used.

During the recovery period with mesadenitis, there may be such recommendations – start doing physiotherapy exercises, be sure to scan and treat all foci of chronic infection, give up diets, smoking and drinking alcoholic beverages.

The author of the article:

Nikitina Olga Ivanovna

therapist, gastroenterologist, KMN

work experience 5 years

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Sore throat and enlarged lymph nodes

Modern methods of diagnostics

For help in diagnosis and treatment, you need to contact a general practitioner. An important role in establishing the causes of sore throat and swollen lymph nodes is played by the initial examination and questioning of the patient. Therefore, it is necessary to provide as detailed answers to the doctor’s questions as possible. Other methods of examination include laboratory and diagnostic studies.

In most cases, symptoms such as sore throat and swollen lymph nodes are caused by inflammation. Depending on the diagnosis, the specialist prescribes the appropriate course of therapy.

Before going to a medical facility, you can take an online self-diagnosis on our website. This simple test will help you determine the cause of a sore throat. But in no case should you self-medicate, this can only exacerbate the problem. You need to visit a doctor. Depending on the causes of the symptom, he will prescribe the appropriate treatment.

Which doctor can help?

If you have a sore throat and swollen lymph nodes, you should consult a general practitioner who will examine you and make the correct diagnosis.

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m. Some diseases are difficult to diagnose as they say “by eye”. Therefore, you need to trust the doctor when prescribing research. After all the tests, the doctor will be able to draw up the correct course of treatment. Remember: accurate diagnosis and correct diagnosis are already 50% of success in treatment!

Treatment of enlarged lymph nodes and sore throat

Medicines are prescribed only by a doctor. Treatment of enlarged lymph nodes and sore throat should be carried out according to his prescription. However, many, striving for a speedy recovery, self-medicate. There are a number of gross errors that can only aggravate the patient’s condition. In particular, with pain in the throat and enlarged lymph nodes, it is not recommended:

• heat and rub problem areas;
• make an iodine mesh in the neck area;
• be exposed to direct sunlight for a long time;
• increase physical activity.

Specialists direct treatment to address the root cause of the discomfort.