P106 | <i>What’s in a lymph node?</i> A case of unexplained fever and lymphadenopathy

Background: Internal Medicine deals with complex cases, frequently with nonspecific presentation, and Fever of Unknown Origin is one of the hardest challenges.Clinical case: A 56-year-old woman came to the ER for persistent hyperpirexia unresponsive to two lines of antibiotics, associated with right inguinal painful lymph node. In her medical history, a psoriatic arthritis treated with methotrexate and adalimumab, and NDD thrombocytopenia. Suspecting an infectious disease, she was investigated for common and opportunistic pathogens, zoonosis and STDs, without significant findings. A gynecological evaluation ruled out PID, transthoracic echocardiogram excluded vegetations, and total body CT confirmed inguinal lymphadenopathy and splenomegaly: only the hypotheses of lymphomatous disease or rare causes remained open. The patient underwent excisional lymph node biopsy, showing subsequent clinical improvement. Although the evolution seemed to lead to a diagnosis of Castleman’s disease, the histological examination was diagnostic for follicular T Helper lymphoma with angioimmunoblastic phenotype. Therefore, the patient was treated with chemotherapy following the CHOEP regimen. A follow-up CT performed after two months showed stable splenic disease, without captating lymph nodes. The patient continued through the oncohematological pathway aimed at marrow transplantation.Conclusions: Angioimmunoblastic T cell lymphomas typically present with nonspecific symptoms; deductive reasoning can help to reach an early diagnosis, thus increasing the possibility of a favourable clinical evolution.