Case 30-2005: A 56-Year-Old Man with Fever and Axillary Lymphadenopathy

N Engl J Med 2005;353:1387-94. Copyright © 2005 Massachusetts Medical Society. A 56-year-old man was referred to the transplantation infectious-disease clinic because of a low-grade fever and left axillary lymphadenopathy. The patient had received a cadaveric kidney transplant five years earlier for polycystic kidney disease. He had been in his usual state of health until three weeks before the referral to the infectious-disease clinic, when he discovered palpable, tender lymph nodes in the left epitrochlear region and axilla. Ten days later a low-grade fever, dry cough, nasal congestion, and night sweats developed, for which trimethoprim–sulfamethoxazole was prescribed, without benefit. He was referred to a specialist in infectious diseases. The patient did not have headache, sore throat, chest or abdominal pain, dyspnea, diarrhea, or dysuria. He had hypertension, gout, nephrolithiasis, gastroesophageal reflux disease, and prostate cancer, which had been treated with radiation therapy two years earlier. He was a policeman who worked in an office. He had not traveled outside of the United States recently. He had acquired a kitten several months earlier and recalled receiving multiple scratches on his hands when he played with it. His medications were cyclosporine (325 mg daily), mycophenolate mofetil (2 g daily), amlodipine, furosemide, colchicine, doxazosin, and pravastatin. Prednisone had been discontinued one year previously. He reported no allergies to medications. The temperature was 36.0°C and the blood pressure 105/75 mm Hg. On physical examination, the patient appeared well. The head, neck, lungs, heart, and abdomen were unremarkable. On the dorsum of the left hand was a single, violaceous nodule with a flat, necrotic eschar on top (Fig. 1); there was no erythema, fluctuance, pus, or other drainage, and there was no sinus tract. The patient said that this lesion had nearly healed, but that he had been scratching it and thought that this irritation prevented it from healing. There was a tender left epitrochlear lymph node, 2 cm by 2 cm, and a mass of matted, tender lymph nodes, 5 cm in diameter, in the left axilla. There was no lymphangitic streaking or cellulitis. The results of a complete blood count revealed no abnormalities (Table 1). Additional laboratory studies were obtained, and clarithromycin (500 mg, twice a day) was prescribed. Within a day of starting treatment, the patient’s temperature rose to 39.4°C, and the fever was accompanied by shaking chills. He was admitted to the hospital. The temperature was 38.6°C, the pulse was 78 beats per minute, and the blood pressure was 100/60 mm Hg. The results of a physical examination were unchanged presentation of case