PMC9165714_01
Timeline of PET/CT imaging throughout the patient's course. (A) PET/CT from Initial presentation with fever and diffuse FDG avid lymphadenopathy. (B) PET/CT showing significant decrease in size and metabolic activity of previously enlarged lymph nodes after two months of antifungal treatment. (C) PET/CT showing complete resolution of lymphadenopathy 4 months after initial presentation.
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PET/CT scan showed extensive, intensely FDG avid lymphadenopathy as well as new diffusely avid splenomegaly ( Figure 1 ). Itraconazole was continued until a follow-up PET/CT 2 months after presentation showed a marked decrease in the size and metabolic activity of his previously enlarged cervical, thoracic, abdominal, and pelvic lymph nodes ( Figure 1 ). Repeat PET/CT 4 months after presentation showed complete resolution of his lymphadenopathy, which was ultimately attributed to disseminated histoplasmosis ( Figure 1 ).
Pathology from Left axillary FNA. (A) Aspirated material of a lymph node shows multiple granulomas. They are charecterized by syncytium cytoplasm and spindled, elongated, carrot shaped and barefoot shaped nuclei (Diff-Quik stain, x200). (B) This small core biopsy shows numerous necrotizing granulomatous inflammation effacing the entire lymphoid tissue. The granulomas are characterized by round to oval structures consisting of epithelioid histiocyties with focal central necrosis. Scattered lymphocytes and multinucleated giant cell are noted (H&E stain X100). (C) Ziehl neelsen stain is negative for mycobacterial organisms (Ziel neelsen stain X400). (D) GMS stain is negative for fungal microorganisms (GMS stain X200).
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Left axillary fine needle aspirate (FNA) and core biopsy showed granulomatous inflammation with negative stains for mycobacteria (Ziehl-Neelsen stain) or fungal organisms (GMS stain) and were also negative for involvement with RCC, lymphoma, or other malignancy ( Figure 2 ).