[Cervical actinomycosis in systemic lupus erythematosus, nephrocalcinosis and distal renal tubular acidosis (type I-RTA)].
METHODS
A 25-year-old woman presented with a painful soft-tissue swelling in the right neck, which made it impossible to assess the right cervical lymph nodes, while other lymph nodes were unremarkable on palpation. For 9 years she had been known to have polyarthritis. All joints were freely mobile and were without deformity or inflammatory signs. Flexion of the left elbow was slightly painful but freely mobile. There was no skin rash.


METHODS
Erythrocyte sedimentation rate was 44 mm/h, there was a leucocytosis of 16,000 granulocytes/ml. There was hypokalaemia (3.5 mEq/l) and a metabolic hyperchloremic acidosis with a pH of 7.27 and a urinary pH of 6.5. Antinuclear and anti-ds-DNA antibodies were raised (ANA: 3.9 multiple of cutoff point [MOC; normal: 0-1.0]; anti-ds-DNA antibodies: 4.0 [normal: 0-1.0])-Fine needle aspiration cytology from the swelling revealed erythrocytes, double-refractory horny lamellae, cellular debris and only a few inflammatory cells. Abdominal ultrasound showed nephrocalcinosis. Microbiological cultures were negative.


METHODS
Assuming a bacterial cause of the swelling antibiotic treatment with Phenoxymethylpenicillin (4 MU/d) was initiated. The local findings rapidly improved and the inflammatory parameters regressed to normal. 16 weeks after the initial admission the abscess recurred and biopsy now revealed actinomycetes with typical granules, confirming cervical actinomycosis. The other symptoms indicated autoimmune disease and, together with previous findings, established the additional diagnosis of lupus erythematodes, which caused the type 1 distal tubular acidosis.


CONCLUSIONS
This case illustrates the basic approach of establishing an all-encompassing diagnosis that brings together seemingly isolated findings. It is especially in systemic disease that such diagnostic strategy will frequently lead to its recognition.
Alscher
D M
DM
Abteilung 4, Schwerpunkte Allgemeine Innere Medizin und Nephrologie, Robert-Bosch-Krankenhaus, Stuttgart. dominik-mark.alscher@dgn.de
Dunst
R
R
Kuhlmann
U
U
D000141:Acidosis, Renal Tubular / Q000150:complications* / Q000175:diagnosis; D000197:Actinomycosis, Cervicofacial / Q000150:complications* / Q000188:drug therapy / Q000473:pathology; D000328:Adult; D001706:Biopsy; D005260:Female; D006801:Humans; D008180:Lupus Erythematosus, Systemic / Q000150:complications* / Q000175:diagnosis; D009397:Nephrocalcinosis / Q000150:complications* / Q000000981:diagnostic imaging; D010404:Penicillin V / Q000627:therapeutic use; D010406:Penicillins / Q000627:therapeutic use; D013363:Submandibular Gland / Q000473:pathology; D014463:Ultrasonography
D010406:Penicillins; D010404:Penicillin V