A Case of Necrotizing Lymphadenitis From Streptococcus pyogenes

Abstract

Necrotizing lymphadenitis (NL) is a rare occurrence of necrotic, nongranulomatous lymphadenopathy. While idiopathic, autoimmune, and viral etiologies are commonly implicated in NL, bacterial etiologies, particularly from Streptococcus pyogenes (S. pyogenes), are exceedingly rare. We present a case of a 25-year-old female who presented with a one-week history of right-sided neck pain, fever, and sepsis. Examination and lab tests revealed an enlarged cervical lymph node measuring 2.4 cm and a positive Streptococcus A test. Four days later, the lymph node increased in size to 3.6 cm despite antibiotic management. Due to concerns of abscess formation and compression of the internal jugular vein, the patient underwent ultrasound-guided lymph node aspiration and biopsy, which revealed purulent fluid and necrosis. In our literature search, only one other case of NL secondary to S. pyogenes has been described, thus highlighting the clinical significance of this presentation. This case emphasizes the complexity of addressing and treating NL and underscores the need to consider bacterial etiologies in the diagnosis.

Keywords: bacterial lymphadenitis; cervical lymph node; cervical lymphadenitis; group a streptococcus pyogenes; kikuchi-fujimoto disease; necrotizing lymphadenitis.

Figure 1. Initial CT on admission showing a necrotic mass measuring 2.4 x 1.7 cm in the right level 2 cervical chain with adjacent sternocleidomastoid myositis and mass effect on the internal jugular vein.

Figure 2. Follow-up CT imaging on day four showing a necrotic mass measuring 3.6 x 1.7 cm in the right cervical chain with adjacent sternocleidomastoid myositis and mass effect on the internal jugular vein.

Figure 3. Follow-up MRI one day after ultrasound-guided drainage showing no recollection of fluid.