A 32-year-old previously healthy man presented to Beth Israel Deaconess Medical Center in Boston (MA, USA) with a 2-week history of fever and a progressively enlarging left-sided neck mass (figure A). His symptoms were preceded by a sore throat 1 month earlier. He had no relevant past medical history or exposures, but he was sexually active with male partners and receiving 300 mg tenofovir combined with 200 mg emtricitabine (orally daily) for HIV pre-exposure prophylaxis. Initial investigations showed a normal white blood cell count of 9·8 × 109 cells per L, a haemoglobin count of 13·4 g/dL, and a platelet count of 339 × 109 cells per L. A peripheral blood smear was normal. Serological tests for cytomegalovirus, Epstein-Barr virus, Toxoplasma gondii, Bartonella spp, and Treponema pallidum were negative for acute infection. Given his ongoing fever, he was treated with vancomycin (1 g intravenously every 8 h) and ampicillin–sulbactam (3 g intravenously every 8 h) for 4 days; however, his fever did not improve. A CT scan of the chest and abdomen showed supraclavicular lymphadenopathy but no additional abnormalities. A CT scan of the neck showed diffuse left-sided lymphadenopathy with cystic necrosis (figure B), and excisional biopsy showed necrotising pyogranulomatous lymphadenitis; stains were negative for any organism. Oropharyngeal nucleic acid amplification testing was positive for Chlamydia trachomatis, and lymphogranuloma venereum serological testing showed an IgA titre of 1/32, an IgG titre of 1/512, and an IgM titre of less than 1/10. Confirmatory testing was done on lymph node tissue by the Centers for Disease Control and Prevention, showing positive immunohistochemistry results for C trachomatis, and a diagnosis of oropharyngeal lymphogranuloma venereum was made. A 21-day course of oral doxycycline was given (100 mg orally twice daily), with complete resolution of the lymphadenopathy.

FigureClinical manifestations of oropharyngeal lymphogranuloma venereum

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(A) Progressively enlarging left-sided neck mass seen on presentation. (B) Diffuse left cervical lymphadenopathy with enhancement and internal necrosis at the left level IIa and IIb lymph node stations.