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Endgames Case Review

Inguinal lymphadenopathy in an HIV seropositive patient

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l2284 (Published 10 July 2019) Cite this as: BMJ 2019;366:l2284
  1. Ranjan Kumar Singh, consultant1,
  2. Dipak Kumar, senior medical officer1
  1. 1ART Center, District Hospital, Khagaria, India
  1. Correspondence to R Kumar Singh dr_ranjankumarsingh{at}yahoo.com

A 40 year old man with HIV presented with a four week history of a painful mass in the left inguinal region and low grade fever. He had been taking antiretroviral drugs (tenofovir, lamivudine, and efavirenz) for the past four years. He had no recent history of animal scratch. Clinical examination revealed multiple massively enlarged fluctuant lymph nodes (3.5-4.5 cm) in the left inguinal region above and below the inguinal ligament, forming a “groove sign” (red arrow, fig 1). Some of the lymph nodes had broken down and formed sinuses. He had oedema of the lower part of the left leg. No lesions were present in the anogenital region. Lymph nodes at other sites in the body were not enlarged. Chest radiograph and ultrasonography of the abdomen were normal. Table 1 shows the relevant laboratory results.

Fig 1
Fig 1

Left inguinal region showing the “groove sign”

Table 1

Laboratory findings

View this table:

Questions

  1. What are the differential diagnoses of inguinal lymphadenitis?

  2. What is the most likely diagnosis?

  3. How would you treat this condition?

1. What are the differential diagnoses of inguinal lymphadenitis?

Differential diagnoses of inguinal lymphadenitis include bacterial cellulitis (Staphylococcus aureus, Streptococcus, etc.) in the lower limbs, syphilis, chancroid, herpes, lymphogranuloma venereum, cat scratch disease, tuberculosis, and lymphoma.

2. What is the most likely diagnosis?

Purulent unilateral tender fluctuant lymph nodes in a HIV seropositive patient with positive Chlamydia trachomatis serology is characteristic of the lymphadenopathic (bubonic) stage of lymphogranuloma venereum (LGV). LGV is a systemic sexually transmitted disease caused by C. trachomatis serovars L1-L3. More than 67% of LGV cases occur in patients with HIV.1

The groove sign is formed in the inguinal region as a result of enlarged lymph nodes above and below the inguinal ligament. It is found in 15-20% of LGV cases.2 It can also be seen in eosinophilic fasciitis3 and non-Hodgkin’s lymphoma.4

3. How would you treat this condition?

Doxycycline (100 mg) orally twice a day for 21 days (for pregnant women with LGV, azithromycin 1 g orally weekly for three weeks).

Aspirate the pus from discharging lymph nodes and apply an antiseptic dressing. Extended antibiotic treatment might be necessary in cases of HIV co-infection if the infection has not been resolved.

Screen for C. trachomatis three months after completing treatment to look for reinfection.5

Contact tracing and presumptive treatment of contacts with doxycycline 100 mg twice a day for seven days is recommended.

Learning point

Classic presentation of LGV includes inguinal lymphadenitis with the formation of buboes.

Differential diagnoses of the sign of groove (groove sign) include: LGV, eosinophilic fasciitis, and non-Hodgkin’s lymphoma.

Patient outcome

The patient was treated with doxycycline (100 mg) twice daily for 21 days with aspiration of fluctuant lymph nodes with a 21 gauge needle. Inguinal lymphadenitis and lymphedema of the left leg resolved completely. However, after a few months, the patient died from meningoencephalitis related to HIV (unrelated to the LGV).

Footnotes

References

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