An 18-year-old girl presented with a progressive bulging mass 2 x 3 cm2 in size, mildly tender, and soft without any fluctuation in 3 weeks located in her rib inter-space 1-2 near the left border of the sternum. She was living in the urban area and was healthy otherwise, except for a history of unpasteurized cheese usage. Intermittent low-grade fever (at night) and sweating were the only complaints. CXR was normal and ultrasonography reported the mass as a lymphadenopathy. Brucella seroagglutination tests, Wright, and 2ME were requested.
Laboratory data showed: WBC = 11,200: Neut = 78%, Lymph = 20%, Mono = 2%, Hb = 11.1, Wright = 1/640, 2ME = 1/80, ESR = 9. Other lab data were not remarkable.
Biopsy of the lesion showed nonspecific inflammation of the lymph node. She was treated with Cap. Doxycycline (100 mg/BID/Po) and Tab. Rifampin (600 mg/day/Po). After 2 months, lymphadenopathy disappeared and no relapse was reported after 1 year follow-up.
The third case was an 18-month-boy referred with a history of multiple, firm, and tender parasternal nodules (about 1.5 x 2 cm2 in size). He showed no constitutional symptoms.
There was no clear history of using unpasteurized dairy products. Wright and Coomb's Wright and all workups were negative. Routine laboratory exams revealed normal results. As a diagnostic approach, excisional biopsy was performed. Grossly, the lesion was cartilaginous with no evidence of necrosis or tumoral involvement. Microscopic examination revealed chronic nonspecific inflammatory process. The smear and culture of biopsied material were negative for tuberculosis or other bacteria. Due to persistent signs and symptoms, follow-up was done by repeated serologic tests which showed four-fold rising in brucella titer (8 weeks later). Treatment was started by Tab. Trimethoprim-sulfamethoxazole (trimethoprim, 8 mg/kg/Po) and Tab. Rifampin (10 mg/kg/Po) and continued for 8 weeks. Good response to therapy was achieved.