Case Presentation: A 40-year-old man presented with a six-hour history of bilateral swollen inguinal regions, subjective fevers, and penile edema. He had a history of recurrent episodes of inguinal lymphadenopathy with associated fevers over the last 15 months. Fevers would persist for a few hours to days with spontaneous resolution. He denied IV drug use, night sweats, recent travel, new medication or sick contacts. He was sexually active with one partner. Surgical history was notable for right and left inguinal hernia repair with “plug” mesh, inguinal nerve pulse ablation, and recent umbilical hernia repair with mesh. Temperature was 98.7F, heart rate 84bpm, blood pressure 106/71 mmHg, respiratory rate 20 breaths/min, oxygen saturation 99% on room air. Inguinal region was mildly erythematous and swollen with tenderness to palpation bilaterally. No inguinal lymph nodes were palpated. Penis was circumcised with mild edema and erythema. WBC was 15.8 K/microliter with 80.9% neutrophils and 11.6% lymphocytes on differential, RPR nonreactive, Chlamydia Trachomatis and Neisseria Gonorrhea PCR negative. Prior workup revealed HIV, histoplasma antigen, ANA, and fungus panel negative.CT abdomen/pelvis without contrast revealed small lymph nodes in the left inguinal region (<8mm, cluster of 4-5). Lower Extremity ultrasound completed one month prior noted a prominent lymph node in the right groin measuring 3.2 x 0.8 x 2.6 cm. CT abdomen/pelvis three months prior revealed no inguinal adenopathy. General surgery was consulted for consideration of excisional biopsy of the lymph node. Further review of patient’s surgical history and imaging revealed that patient likely had inflammation of his inguinal region secondary to mesh placement from prior inguinal hernia surgeries. He was treated with NSAIDs for symptom relief. Mesh removal is being considered by a specialist.
Discussion: Lymphadenopathy is commonly encountered by internists and requires a systematic approach to develop an appropriate differential diagnosis. Evaluation of a patient with lymphadenopathy should include age, location of the lymphadenopathy, and associated symptoms (fever, weight loss, night sweats). Physical exam will assess whether the lymph nodes are tender, warm, and erythematous, signifying a potential local infection; hard and fixed, indicating a potential malignancy; or rubbery and mobile, which may be suggestive of lymphoma. The differential will cover three broad categories: infectious, malignant, and benign non-infectious lymphadenopathy. Infectious and malignant are the two categories that most are familiar with, whereas benign, non-infectious causes of lymphadenopathy are discussed less frequently. Granulomatous inflammation, drugs, reactive lymphoid hyperplasia, and foreign bodies are a few possible etiologies of benign, non-infectious lymphadenopathy. A foreign body reaction, in this case implanted mesh, is an under recognized cause of lymphadenopathy.The extent of a reaction caused by a foreign body depends on the amount and structure of the incorporated material. Hernia repairs standardly use mesh as mesh leads to lower risk of hernia recurrence and postoperative pain. Foreign body reactions should be included on the differential diagnosis for device infections.
Conclusions: A systematic approach to lymphadenopathy in the hospitalized patient can help a clinician reach a diagnosis. With a foreign body present, hospitalists could consider the object as a possible underlying etiology of lymph node enlargement.