Indan Journal of Medical Research Indan Journal of Medical Research Indan Journal of Medical Research
  Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login  
  Home Print this page Email this page Small font sizeDefault font sizeIncrease font size Users Online: 3440       

   Table of Contents      
CLINICAL IMAGE
Year : 2020  |  Volume : 152  |  Issue : 7  |  Page : 110-111

Retropharyngeal abscess in cutaneous T-cell lymphoma, resembling immune reconstitution syndrome


Department of Nuclear Medicine & Molecular Imaging, Amrita Institute of Medical Sciences, Cochin 682 041, Kerala, India

Date of Submission19-Nov-2019
Date of Web Publication25-May-2021

Correspondence Address:
Padma Subramanyam
Department of Nuclear Medicine & Molecular Imaging, Amrita Institute of Medical Sciences, Cochin 682 041, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_2179_19

Rights and Permissions

How to cite this article:
Subramanyam P, Palaniswamy SS. Retropharyngeal abscess in cutaneous T-cell lymphoma, resembling immune reconstitution syndrome. Indian J Med Res 2020;152, Suppl S1:110-1

How to cite this URL:
Subramanyam P, Palaniswamy SS. Retropharyngeal abscess in cutaneous T-cell lymphoma, resembling immune reconstitution syndrome. Indian J Med Res [serial online] 2020 [cited 2021 Aug 4];152, Suppl S1:110-1. Available from: https://www.ijmr.org.in/text.asp?2020/152/7/110/316764

Patient's consent obtained to publish clinical information and images.


A 55 year old diabetic male, recently diagnosed non-Hodgkin's lymphoma (NHL, cutaneous T cell) presented to department of Medical Oncology, Amrita Institute of Medical Sciences, Cochin, India, in October 2019, with throat pain. Positron emission tomography–computed tomography (PET-CT) showed fluorodeoxyglucose (FDG)-avid lower cervical nodes [Figure 1]A, FDG avid hypodense collection in the retropharyngeal space and extensive unsuspected mediastinitis [Figure 1]B. Cryptococcus neoformans was isolated on culture from the site of abscess. Skin and subcarinal nodes were biopsied [Figure 1]C, [Figure 1]D, [Figure 1]E. Amphotericin B (0.8 mg/kg/day) and flucytosine (100 mg/kg/day in 4 divided doses) were given, however, after three days, the patient developed high fever, malaise, oliguria and septic shock. Lactate dehydrogenase, inflammatory markers, CD4+ cells were elevated and the illness mimicked immune reconstitution inflammatory syndrome (IRIS) usually described in HIV patients post-antiretroviral therapy. However, in this non-HIV, NHL (cutaneous T cell type) patient with retropharyngeal abscess, extensive mediastinitis (with tracking sinuses) mimicked IRIS (type 1) after starting antifungal therapy. FDG PET/CT was incremental in upstaging lymphoma (stage IIE) and illustrated all sites of occult infection in neck, beneath sternocleidomastoid, and mediastinum; facilitating complete surgical debridement and faster amelioration of symptoms. Phototherapy (Psoralen and ultraviolet light A i.e PUVA), immunomodulators like steroids were started. The patient showed clinical improvement after 4 weeks of initiating antifungal therapy.
Figure 1: (A) Fused coronal 18F FDG PETCT (Fluorodeoxyglucose positron emission tomography –computed tomography) image (head to mid-thigh) shows FDG avid bilateral lower cervical lymph nodes (arrows, SUV Max 3.4) and additional splenic involvement (SUV Max 6.7), thereby upstaging NHL to Stage IIE, as per Ann Arbor classification. (B) Coronal PET images (arrow) depict FDG avid retropharyngeal collection and sinus tracking into prevascular, paracardiac spaces, around pericardium and into mediastinum on both sides (SUV Max 17.2). Infection was also noted beneath the right sternocleidomastoid. A large FDG avid subcarinal node was also noted. (C) High-resolution magnified skin biopsy sections H and E, ×40 showing thinned out epidermis, lymphoid infiltrate at dermoepiderma junction with cytological atypia. Cells showing epidermotropism and Pautrier's microabscess formation – suggesting Cutaneous T cell lymphoma. (D) Low-magnification images of subcarinal lymph node biopsy showing infiltration of polymorphic cells with high endothelial venule-like vessels (H and E, ×10) mimicking IRIS. (E) High magnified image of lymph node H and E, ×40 shows proliferation of medium to large-sized lymphoid cells with a clear cytoplasm (clear cells). The cells are CD3+ and CD4+. Findings are mimicking immune reconstitution inflammatory syndrome type I but clinical condition improved with antifungal therapy.

Click here to view


Acknowledgment: Authors acknowledge Dr K Pavithran, Clinical Professor, Department of Medical Oncology, Amrita Institute of Medical Sciences, Cochin, Kerala for referring the patient

Conflicts of Interest: None.


    Figures

  [Figure 1]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Article Figures

 Article Access Statistics
    Viewed154    
    Printed0    
    Emailed0    
    PDF Downloaded29    
    Comments [Add]    

Recommend this journal