10 September 2021
: Case report 
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 Karsulovic12ABCDEFG*, Lia P. Hojman3ACDEF, Daniela L. Seelmann1ABCFG, Pamela A. Wurmann1ABCDEFGDOI: 10.12659/AJCR.932751
Am J Case Rep 2021; 22:e932751
Table 1. Baseline and post-COVID-19 clinical features in all 3 cases.
| Features | Case 1 | Case 2 | Case 3 |
|---|---|---|---|
| Age | 28 years old | 25 years old | 68 years old |
| Gender | Male | Female | Female |
| Disease | Mixed connective tissue disease | Lupus | Lupus |
| Basal involvement | Lung and cutaneous | Articular, hematologic and cutaneous | Articular and cutaneous |
| Current treatment | Hydroxychloroquine | Hydroxychloroquine | Hydroxychloroquine |
| Disease status pre-SARS-CoV-2 | Inactive | Inactive | Inactive |
| SARS-CoV-2 infection severity | Mild (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 PCR | Positive | Positive | Positive |
| SARS-CoV-2 (second) nasopharyngeal PCR | Negative | Negative | Not done |
| SARS-Cov2 antibodies | Negative | Not done | Not done |
| Time to DL initiation | 3 weeks | 4 weeks | 4 weeks |
| Lymph nodes territories Involved | Cervical, axillary, internal mammary, perihepatic and iliac | Cervical and axillary | Cervical, supraclavicular, intra-mammary, axillary and diaphragmatic |
| Other diseases rule-out by tests | Thoracic CT, pulmonary function tests, echocardiogram, and lymph tissue biopsy | Thoracic, abdomen and pelvis CT, mammography, and mammary echography | Cervical and Thoracic CT, mammography, and mammary echography, protein electrophoresis, immunoglobulin count, lymph tissue biopsy |
| Biopsy report | Cervical: Multiple lymphoid follicles with lymphoplasmacytic and histiocytic infiltrate. CD20 and CD3 reactive pattern, BCL2 reactive pattern and CD10+ | Not done | Cervical: Lymphoid follicles with mild histiocytic infiltrate. Reactive markers pattern |
| Image description | Multiple 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 mm | Multiple cervical lymph nodes ranging from 15 to 20 mm. Bilateral axillary lymph nodes ranging from 10 to 15 mm. All described as reactive | Multiple 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 duration | 41 days | 21 days | 58 days |
| Inflammatory parameters | CRP ×3 times normal valueESR: 73 mm/hr | CRP ×2 times normal valueESR: 46 mm/h | CRP ×5 times normal valueESR: 66 mm/h |
| Autoantibodies | Not done | Lupus anticoagulant: PositiveVDRL: Positive | Anti-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 tests | EBV serology: Negative CMV serology: Negative HIV: Negative | FTA-ABS: Negative HIV: Negative | EBV serology: Negative CMV serology: Negative HIV: Negative |
| DL Treatment | Mycophenolate Mofetil 2 g a dayPrednisone 20 mg a day with descending tapering | Mycophenolate Mofetil 1 g a day (reinitiated)Prednisone 40 mg a day with descending tapering | Prednisone 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. | |||