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Year : 2014 | Volume : 2 | Issue : 1 | Page : 53 - 54  


Case Reports
Granulomatous Lymphadenopathy Masquerading as Pleomorphic Adenoma: A Clinical and Diagnostic Dilemma

Ram Babu1, Sudhir Kumar Vujhini2, Prathima3, Ram Manohar Lohia4, Kandukuri Mahesh Kumar5

1Assistant Professor of Pathology, E.S.I Model Hospital, Nacharam, Hyderabad, Andhra Pradesh.

2Associate Professor of Pathology, MRIMS, Suraram, Hyderabad, Andhra Pradesh.

3Assistant Professor of Pathology, Osmania Medical College, Hyderabad, Andhra Pradesh

4Department of Radiology, E.S.I Model Hospital, Nacharam, Hyderabad, Andhra Pradesh 5Assistant Professor, Department of Pathology, MRIMS, Suraram, Hyderabad

Abstract:

Lymphadenopathy can masquerade as other pathological entities due to their proximity to many sites, thus clinical misjudgment can happen. Ours is such example where Granulomatous cervical lymphadenopathy is clinically thought of as Pleomorphic adenoma of Parotid gland. They need careful review, radiological correlation before committing for final impression.

Key words: Parotid, Pleomorphic adenoma, Lymphadenopathy, Granulomatous Cervical lymphadenitis, Fine needle aspiration cytology.

Corresponding Author: Dr. Sudhir Kumar Vujhini, Dept. of Pathology, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad Andhra Pradesh. E-mail: vujhini07@yahoo.com

Introduction:

Granulomatous lymphadenitis (most probably in our society of tuberculous origin) presents as enlarged nodes and in late stages as matted nodes at various sites. Cervical area is the most often affected site and can be unilateral, bilateral based on the stage of presentation of disease. Due to the proximity of lymph nodes to many organs they are often clinically misjudged as pathological entity of these presumed affected organs. Few such examples are lymph nodal enlargements in vicinity of salivary glands, in axillary mastoid area.

Case Report:

A 30 year old male presented to surgical outpatient department with right sided neck swelling extending from parotid to upper cervical region. He had general malaise and occasional cough but had no fever. Case was taken up for elective surgery and surgical profile was ordered along with FNAC. Pending reports he was put on antibiotic, anti inflammatory and anti histamine drugs.

During examination in cytology room patient informed that swelling first started below the ear and extended to the neck below. On palpation non tender swelling appeared matted and seen extending from parotid region to right upper posterior cervical region. The characteristic sign of lifting of ear lobe seen in parotitis was not observed.

FNAC was attempted under aseptic conditions keeping in mind the possibility of parotid pathology as first choice apart from cervical lymphadenitis. Blood mixed aspirate was obtained and stained slides of alcohol fixed and air dried smears were examined. Cytology revealed Epithelioid clusters along with Serous acinar, Duct acinar clusters of variable size and cohesiveness along with occasional Langhans giant cell and lymphocytes in hemorrhagic background. With these findings Granulomatous lesion in parotid was the initial impression but Granulomatous Cervical lymphadenitis was not ruled out. Final impression was deferred and Ultrasound findings were sought in view of the diagnostic dilemma. Radiologist unequivocally gave the findings in favor of cervical lymphadenopathy with significant noting that intraparotid lymph nodes were also enlarged and parotid itself was unaffected. Also other side cervical nodes were also enlarged though clinically not palpable and rest of the neck area showed no abnormality. Based on this opinion slides were reviewed which showed same cytology findings; reaspirate smear for AFB was negative. CBC shows Hb – 14.1 gm%, TLC – 7500/cu.mm, DC- polymorphs -62%, lymphocytes-31%, eosinophils-03%, monocytes-04%; platelet count- 2.01 lakhs/ cu.mm, ESR -24 in first hour. Final impression was given as “Suggestive of Granulomatous Lymphadenitis, probably of tuberculous origin extending to right Parotid gland “was issued. This was the cytology opinion keeping in view the possibility that aspiration needle must have picked parotid elements and well supported by Radiologist opinion.

Patient was deferred for surgery, put on Anti Tuberculosis therapy and has made good progress with significant resolution of size of nodular swelling 2 weeks later.

Figure (left) showing normal acini x100. Inset x400 (Leishman stain). Right side shows cluster of Epithelioid macrophages

 

Discussion:

In clinical practice it is not uncommon to see some lesions masquerading as pathology of other organs in proximity. [1, 2] It is prudent in such cases to advice more caution before starting therapy. Granulomatous Sialadenitis [3] of parotid caused by Sarcoidosis, Tuberculosis [4] or duct obstruction was considered in differential diagnosis. Mycosis would reveal typical fungal elements and as in TB, Sarcoidosis and in Pleomorphic adenoma extensive involvement of the parotid would be present. All of these were not present in this case and thus ruled out as supported by Ultrasound findings [5] which showed involvement to some extent of intra parotid lymph nodes and gland itself being unaffected. Chest radiological signs and symptoms related to skin, eyes etc. were absent thus further ruling out Sarcoidosis. Clinical acumen along with discussion among Clinicians, Pathologists and Radiologists would help to resolve the dilemma. In this case as mentioned review of smears, ultrasound findings helped to narrow down to final impression. It is also significant in terms of patient morbidity as treatment differs according to the pathology. In our case possibility of Sarcoidosis, Pleomorphic adenoma and other entities were ruled out thus avoiding misinterpretation and subsequent morbidity that would have caused if final impression was given otherwise. Thus one must not overlook the importance of differential diagnosis and to ask for other relevant investigations to look into other possibilities to benefit the patient.

References:

  1. Van der Walf JD, Leake J.Granulomatous Sialadenitis of the major salivary glands. A clinocopathological study of 57 cases. Histopathology 1987.
  2. Bruneton JN, Mourou MY. Ultrasound in salivary gland disease. ORL J otorhinolaryngol Relat Spec 19993, 55: 284-289.
  3. Pad field CJH Choyce MQ, Eveson JW, Xanthogranulomatous sialadenitis, Histopathology 1993, 23:488-495.
  4. Singh B, Maharaj TJ, Tuberculosis of the parotid gland. Clinically indistinguishable from neoplasm. J Laryngol Otol 1992, 106:929-931.
  5. Traxler M, Schurawitzki H, Ulmc et al, Sonography of non neoplastic disorders of the salivary glands. Int J Oral Malliofac Surg 1992, 21:360-363.

FOR FIGURE: PLEASE REFER TO PDF FILE

Acknowledgement: The author wishes to express thanks to Dr R Kataria, Medical Superintendent, ESIC Model Hospital, Nacharam, Hyderabad who has allowed us to publish this article.

Source of Support: Nil. Conflict of Interest: None.

 

 





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