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10 September 2021: Articles

Diffuse Lymphadenopathy Syndrome as a Flare-Up Manifestation in Lupus and Mixed Connective Tissue Disease Following Mild COVID-19

Challenging differential diagnosis, Unusual or unexpected effect of treatment, Rare coexistence of disease or pathology

Claudio Karsulovic A* , Lia P. Hojman A , Daniela L. Seelmann A , Pamela A. Wurmann A

DOI: 10.12659/AJCR.932751

Am J Case Rep 2021; 22:e932751

Table 1. Baseline and post-COVID-19 clinical features in all 3 cases.

FeaturesCase 1Case 2Case 3
Age28 years old25 years old68 years old
DiseaseMixed connective tissue diseaseLupusLupus
Basal involvementLung and cutaneousArticular, hematologic and cutaneousArticular and cutaneous
Current treatmentHydroxychloroquineHydroxychloroquineHydroxychloroquine
Disease status pre-SARS-CoV-2 InactiveInactiveInactive
SARS-CoV-2 infection severityMild (no respiratory insufficiency and CALL Score 5) Mild (no respiratory insufficiency or desaturation, No ER consultation)Mild (no respiratory insufficiency or desaturation, CALL Score 4)
SARS-CoV-2 (first) nasopharyngeal PCRPositivePositivePositive
SARS-CoV-2 (second) nasopharyngeal PCRNegativeNegativeNot done
SARS-Cov2 antibodiesNegativeNot doneNot done
Time to DL initiation3 weeks4 weeks4 weeks
Lymph nodes territories InvolvedCervical, axillary, internal mammary, perihepatic and iliacCervical and axillaryCervical, supraclavicular, intra-mammary, axillary and diaphragmatic
Other diseases rule-out by testsThoracic CT, pulmonary function tests, echocardiogram, and lymph tissue biopsyThoracic, abdomen and pelvis CT, mammography, and mammary echographyCervical and Thoracic CT, mammography, and mammary echography, protein electrophoresis, immunoglobulin count, lymph tissue biopsy
Biopsy reportCervical: Multiple lymphoid follicles with lymphoplasmacytic and histiocytic infiltrate. CD20 and CD3 reactive pattern, BCL2 reactive pattern and CD10+Not doneCervical: Lymphoid follicles with mild histiocytic infiltrate. Reactive markers pattern
Image descriptionMultiple cervical and axillary lymph nodes ranging from 12 to 15 mm. Internal mammary and retro-pectoral lymph nodes ranging from 9 to 12mm. Perihepatic and iliac lymph nodes ranging from 15 to 16 mmMultiple cervical lymph nodes ranging from 15 to 20 mm. Bilateral axillary lymph nodes ranging from 10 to 15 mm. All described as reactiveMultiple bilateral cervical, supraclavicular, and axillary reactive lymph nodes ranging from 15 to 16 mm. One 8-mm anterior diaphragmatic lymph node was also described
Flare duration41 days21 days58 days
Inflammatory parameters CRP ×3 times normal valueESR: 73 mm/hrCRP ×2 times normal valueESR: 46 mm/hCRP ×5 times normal valueESR: 66 mm/h
Autoantibodies Not doneLupus anticoagulant: PositiveVDRL: PositiveAnti-dsDNA: PositiveAnti-Ro60: PositiveAnti-Ro52: PositiveAnti-Sm: Positive
Other activity lab tests C3: 85mg/dl (normal) C4: 17mg/dl (normal)C3: 94mg/dl (normal) C4: 12mg/dl (low)C3: 66mg/dl (low) C4: 18mg/dl (normal)
Other lab testsEBV serology: Negative CMV serology: Negative HIV: NegativeFTA-ABS: Negative HIV: NegativeEBV serology: Negative CMV serology: Negative HIV: Negative
DL TreatmentMycophenolate Mofetil 2 g a dayPrednisone 20 mg a day with descending taperingMycophenolate Mofetil 1 g a day (reinitiated)Prednisone 40 mg a day with descending taperingPrednisone 20 mg a day with descending tapering
* At the time of DL diagnosis;
# CALL Score results: Pat1: C1A1L2L1 Pat3: C1A1L1L1;
## SLEDAI Score: Pat2: Less than 3 points // Pat3: Less than 3 points.

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923