VirchowTroisier's node in a haemodialysed patient: it is not always cancer
Anne-Cecile Galloy1,
Jean-Louis Christophe1,
Emmanuel Cambier2,
Michel Petein3 and
David Verhelst1
1 Department of Nephrology and 2 Department of Surgery, Hopital Saint-Joseph, Gilly and3
Department of Pathology, Institut de Génétique et Pathologie, Loverval, Belgium
Correspondence and offprint requests to: David Verhelst, MD, Department of Nephrology, Hopital Saint-Joseph, 6, rue de la Duchère, 6060 Gilly, Belgium. E-mail: david.verhelst{at}skynet.be
Keywords: haemodialysis; lymphadenopathy; tuberculosis
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Introduction
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An enlarged left supraclavicular lymph node (VirchowTroisier's node) classically heralds a diagnosis of metastatic cancer, usually originating from an abdominal organ [13]. We report on a patient with this presentation in whom the histological examination of the node yielded a completely different diagnosis.
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Case
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A 58-year-old Caucasian patient was admitted to the hospital in June 2003 for evaluation of a tender left supraclavicular swelling. He was on maintenance haemodialysis for 2 years for end-stage vascular nephropathy. His past medical history included aorto-femoral bypass in 1995, hypertension and gastric ulcer. He did not have a history of diabetes or alcohol consumption, or a recent history of arthralgia, anorexia, productive cough, dyspnoea, or exposure to animals or other ill persons. His father had had pulmonary tuberculosis
40 years earlier.
His blood pressure was 145/86 mm Hg, pulse was 76/min and temperature 36°C. In the left cervical and supraclavicular region, he had
5 painful nodes measuring 0.52 cm in diameter, with local erythema. Laboratory investigation revealed: a white cell count of 6080/mm2, with a normal differential count; haemoglobin 12.1 g/dl; creatinine 10.6 mg/dl; serum albumin 4.4 g/dl; calcium 9.4 mg/dl; phosphate 5.9 mg/dl; intact parathyroid hormone (iPTH) 121 pg/ml; total alkaline phosphatase 72 IU/l; and C-reactive protein 0.5 mg/dl. Serologies for Toxoplasma gondi, Chlamydia trachomatis and Brucella abortis were negative. His chest X-ray was normal. A VirchowTroisier's node heralding a malignant disease was the diagnosis suspected. A thoracic computerized tomography confirmed the presence of multiple small calcified lymph nodes in the left supraclavicular area (Figure 1), as well as in the mediastinum. An oesophago-gastro-duodenoscopy excluded a gastric cancer. He was referred to an otolaryngologist for a fibreoptic examination, which found no abnormalities. Surgical excision of the enlarged lymph nodes was performed. Light microscopic examination revealed granulomatous inflammation, with lymphocytes, histiocytes, many neutrophils and giant cells surrounding caseous necrosis (Figure 2). Auramine staining showed multiple fluorescent bacilli, which proved to be acid-fast on Ziehl staining (Figure 3). A polymerase chain reaction (PCR) assay of the tissue sample was positive for Mycobacterium tuberculosis. Antituberculous therapy with rifampin, isoniazid and ethambutol was started, and resulted in the resolution of clinical symptoms.

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Fig. 2. A caseating granuloma showing a zone of radially oriented epithelioid histiocytes, lymphocytes and Langhans giant cells.
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Discussion
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In this haemodialysed patient presenting with left supraclavicular adenopathy, a diagnosis of M. tuberculosis infection was established by histological examination, specific cultures and a PCR assay of the excised tissue. The diagnosis was confirmed further by the patient's response to antituberculous therapy. To the best of our knowledge, this is the first reported case of a dialysed patient with left supraclavicular lymphadenopathy (VirchowTroisier's node) that turned out to be tuberculous.
Peripheral lymphadenopathy without an obvious cause detected after a careful history and physical examination remains a diagnostic dilemma. Distinguishing between localized and generalized lymphadenopathy can help to formulate a differential diagnosis. Generalized lymphadenopathy may be due to a large number of systemic diseases, many of which may be recognized on the basis of other findings. The most common and important diseases causing generalized lymphadenopathy are summarized in Table I.
As for localized lymphadenopathy, the differential diagnosis depends on the location. Supraclavicular lymphadenopathy is highly associated with malignancy. In two studies, malignancies were found in 34 and 50% of patients with this presentation [1,2]. Right supraclavicular lymphadenopathy is known to be associated with cancer in the mediastinum, lungs or oesophagus [2]. Left supraventricular adenopathy (VirchowTroisier's node) suggests abdominal malignancy [2,3].
Despite the close relationship between supraclavicular adenopathy and malignancies, other diagnoses must be considered, particularly tuberculous lymphadenitis. In a haemodialysed patient, this diagnosis must be considered, because there is an increased risk (6.9- to 52.5-fold) of tuberculosis in that population compared with the general population [4]. The reasons for this higher incidence are not clearly identified, but some hypotheses have been proposed. In uraemia, there is a decreased T-cell response, as indicated by the high rate of anergy to intracutaneously administered antigens, reported to be as high as 32 and 40% [5,6]. Other factors that might contribute to the decreased immunity are malnutrition, vitamin D deficiency [7] and hyperparathyroidism [8].
As illustrated by our case, the symptomatology of tuberculous infection is often insidious and non-specific, but the presence of calcifications helps make the diagnosis. In dialysis patients, the localization of tuberculosis is often (6492%) extrapulmonary [4,911]. Tuberculous peritonitis makes up the largest part of the total number of cases of tuberculosis in patients on continuous ambulatory peritoneal dialysis [4,9]. The other sites for extrapulmonary tuberculosis are cervical lymph nodes, bone marrow, spine, brain, pericardium, cutaneous tissue and the genitourinary system [9]. Tuberculosis remains a significant cause of death in uraemic patients. Chuang et al. reported a mortality rate of 17.6% [9], but the mortality rate may be as high as 75% [10]. Therefore, early diagnosis and prompt treatment are the major determinants of the outcome.
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Teaching point
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Although a palpable left supraclavicular lymphadenopathy evokes the diagnosis of VirchowTroisier's node associated with cancer, physicians should keep in mind the possible diagnosis of tuberculous lymphadenitis. Histological and microbiological examinations are required to both establish the diagnosis and select the appropriate treatment.
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Acknowledgments
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Conflict of interest statement. None declared.
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