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Diagnosis at first sight
A man with recurrent axillary abscess
Un hombre con absceso axilar recurrente
Gamze Durmaza, Esin Beycana, Abdurrahman Kayaa,
Corresponding author
dr.abdkaya@hotmail.com

Corresponding author.
, Ali Mertb
a Department of Infectious Diseases, İstanbul Training and Research Hospital, Turkey
b Infectious Diseases and Clinical Microbiology, Faculty of Medicine, İstanbul Medipol University, Turkey
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical description of the case</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 35-year-old male presented with complaints of a 15-day history of a painful swelling under his right armpit and fatigue&#46; His physician prescribed amoxicillin&#47;clavulanic acid and ciprofloxacin for a possible bacterial infection but no regression was observed&#46; Physical examination revealed a tender&#44; erythematous mass in the right axillary region&#44; measuring approximately 3<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm in diameter&#44; without fluctuation&#46; In his medical history&#44; he had a cat at home but no bite and scratch were noted&#46; The same antibiotics were continued&#46; The patient&#39;s laboratory results were as follows&#58; leukocyte count 4720&#47;mm<span class="elsevierStyleSup">3</span>&#59; hemoglobin&#58; 14&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; hematocrit 43&#37;&#59; C-reactive protein&#58; 23<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#59; sedimentation rate 8<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#46; Ultrasonography &#40;USG&#41; revealed a reactive appearance of lymph node with a distinct cortex and diffuse thickening of the cortex in the right axillary region measuring 33<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>22<span class="elsevierStyleHsp" style=""></span>mm&#46; Other examinations were normal&#46; Urinalysis&#44; basic chemistry&#44; and hepatic function testing results were within normal limits&#46; Serologies for syphilis&#44; human immunodeficiency virus&#44; Epstein-Barr virus&#44; toxoplasmosis&#44; cytomegalovirus and brucellosis were unremarkable&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis and evolution</span><p id="par0010" class="elsevierStylePara elsevierViewall">Despite the administration of 2 weeks of antibiotics&#44; the patient reported further enlargement of the swelling in the right axillary region&#44; increased erythema&#44; and fluctuation of the mass &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; USG showed a dense&#44; echogenic fluid collection measuring 53<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>47<span class="elsevierStyleHsp" style=""></span>mm in the subcutaneous superficial region of the right axilla&#44; consistent with an abscess&#46; Fine needle aspiration was performed from the abscess and the material was sent for analysis for cat scratch disease &#40;CSD&#41;&#44; tuberculosis and other infections &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The sample revealed predominantly mononuclear leukocytes with no bacteria observed on Gram staining&#46; Cultures of the material from the abscess in solid and liquid media were sterile&#46; Chest X-ray was normal and the tuberculin skin test was negative&#46; The Ehrlich&#8211;Ziehl&#8211;Neelsen&#44; culture and PCR of the sample for tuberculosis were negative&#46; The antibiotics were continued after drainage&#46; However&#44; 5 days later&#44; the swelling reappeared&#46; The mass was re-drained and the aspirate was re-analyzed but no specific etiology was reached&#46; The sample was tested for <span class="elsevierStyleItalic">Bartonella</span> spp&#46; by PCR and the result was positive&#46; After the administration of azithromycin&#44; the mass decreased in size and the pain gradually resolved within ten days&#46; The patient has been doing well without recurrence for 3 months&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">CSD is a rare bacterial infection that is usually transmitted from a scratch or bite from a cat infected with <span class="elsevierStyleItalic">Bartonella henselae</span>&#44; as well as from exposure to cat-fleas infected with the bacteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1&#44;2</span></a> In our patient&#44; upon re-evaluation of the patient&#39;s history&#44; it was revealed that he worked in an area surrounded by numerous fleas-infested cats&#46; He admitted to be bitten several times from fleas and there were some bite marks near the abscess &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; arrows&#41;&#46; CSD often begins with a skin lesion at the site of inoculation and then involves the lymph nodes&#46; It typically persists for one to three weeks&#46; However&#44; this lesion is not seen in flea-borne infection as in our case&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> Enlarged lymph nodes appear proximal to the inoculation site and are almost always tender&#44; often have erythema of the overlying skin&#44; and occasionally suppurate&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> Most CSD are self-limited and do not require medical therapy&#46; In some cases&#44; azithromycin is an effective choice and shorten the duration of symptoms&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The differential diagnosis of axillary lymphadenopathy &#40;LAP&#41; includes pyogenic lymphadenitis&#44; cat scratch disease&#44; tularemia&#44; tuberculosis&#44; toxoplasmosis&#44; HIV&#44; lymphoma and metastatic cancer&#46; The first four conditions can lead to abscess formation over time&#46; Acute suppurative lymphadenitis is often caused by <span class="elsevierStyleItalic">Staphylococcus aureus</span> or group A <span class="elsevierStyleItalic">Streptococcus</span>&#46; Both bacteria are easily seen on Gram stain and grow on culture media&#46; They also respond well to the antibiotics mentioned above and to drainage&#46; On the other hand&#44; a diagnosis of lymphoma is unlikely because the erythrocyte sedimentation rate was normal&#44; there were no B symptoms&#44; and the lesion was completely healed&#46; Tularemia can also cause similar symptoms&#47;findings and is associated with recent exposure to the outdoors&#44; animals or insects&#46; However&#44; there were no index cases in the surrounding area&#46; Additionally&#44; tularemia does not respond to azithromycin&#46; In countries where tuberculosis is endemic&#44; it is considered the primary etiology of fluctuating LAP&#46; In our case&#44; all tests were negative for tuberculosis&#46; In addition&#44; tuberculosis LAPs are frequently localized in the cervical region&#46; In our patient&#44; serological tests for CSD could not be performed and the biopsy was not taken&#44; nor was the sample stained with Warthin-Starry stain&#46; In CSD&#44; axillary LAP is a common feature&#44; and these clinical symptoms and the development of suppuration are typical&#46; This case was considered as CSD based on patient history&#44; the positive PCR result&#44; despite a 10&#8211;20&#37; of false positive rate&#44; and the exclusion of alternative diseases&#46; Its response to azithromycin further supported the diagnosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion&#44; CSD can present as a lymphadenopathy without a history of cat scratch and bite&#46; If treatment is delayed&#44; suppuration develops in the lesion&#44; thereby becoming abscess formation&#46; In such situation&#44; multiple drainages may be also required in addition to the administration of antibiotic&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">There is no conflict of interest&#46;</p></span></span>"
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Article information
ISSN: 0213005X
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos