From the University of Louisville School of Medicine, Department of Pediatrics (Drs Kurbasic and Jones), and Kosair Children's Hospital, Department of Pediatric Radiology (Dr Maxfield), Louisville, Ky.
A 2-YEAR-OLD BOY presented with a 6-week history of enlarged lymph nodes in his right axilla and arm. Other symptoms included a temperature of 38.8°C, a mild cough, abdominal pain, and decreased activity and appetite. Prior chest radiographs had revealed bilateral pulmonary opacities in the upper lobes. Previous outpatient therapy with antimicrobials had shown no response. The patient lives in a rural area and has a kitten and 2 dogs. The family reported no knowledge of exposure to tuberculosis or other transmissible diseases.
Physical examination revealed tender, mobile, 1- to 2-cm, nonfluctuant lymph nodes in the right axilla, mid arm, and epitrochlear regions. The liver and spleen were mildly enlarged. Linear erythematous excoriations were present on the right side of the chest and a healing papular lesion was observed on the dorsum of the right arm.
Computed tomography of the chest was performed and the results are shown in Figure 1, Figure 2, and Figure 3. Results of a purified protein derivative test were negative. Laboratory studies including fungal and Bartonella species serology tests were inconclusive. Excisional biopsy of the lymph node of the mid arm was performed.
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