Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

A 64-year-old female with recently diagnosed Waldenström's macroglobulinemia presented with pain and swelling in the neck. Three weeks prior, she had accidentally punctured her neck with her fingernail, leading to initial swelling. She visited the ER, but workup showed no acute infection. A contrast-enhanced CT scan revealed enlarged bilateral cervical lymph nodes. Over the next two weeks, the swelling became increasingly painful. On presentation, she had sharp, localized pain (10/10 intensity), tachycardia, and a 3x3 cm swelling on the right side of her neck, with redness, warmth, and tenderness. Laboratory results showed lymphocytic leukocytosis (WBC 31.5, lymphocyte 24.8%, neutrophil 6.1%). A repeat contrast-enhanced CT scan showed a 5x5 cm ring-enhancing lesion in the subclavicular space. Ultrasound-guided drainage with indwelling drain placement was performed, and cultures grew Streptococcus pneumoniae. The patient had been vaccinated with PCV13 and PPSV23 18 years ago. She was treated with IV ceftriaxone for 48 hours, followed by oral cephalexin for 14 days.She was discharged with the drain in place After infection resolution, she received repeat vaccinations with PCV, meningococcal, and Haemophilus influenzae vaccines. Notably, a previous PET scan showed marked splenomegaly with increased FDG uptake. Streptococcus pneumoniae, a common respiratory pathogen, can cause opportunistic cutaneous infections, particularly in patients with neutropenia or hyposplenism. Those with Waldenström's macroglobulinemia (WM) are at increased risk of sinopulmonary infections, pyelonephritis, and septicemia due to immune dysregulation from somatic mutations in the"V". "D" and "J/H' segments of immunoglobulin. These mutations impair affinity maturation and memory B-cell formation, leading to a suboptimal response to vaccinations against pathogens like Streptococcus pneumoniae, Staphylococcus aureus, and Varicella, similar to multiple myeloma. Severe infections with gram-positive organisms, including osteomyelitis and sepsis, have been reported in WM. Our patient, with splenomegaly but no signs of immunodeficiency or splenic sequestration, was treated with IV antibiotics and continuous drainage for 48 hours due to the risk of severe infection. She was revaccinated to dye functional hyposplenism and risk of recurrent infection Recurrent infections in B-cell neoplasms with normal neutrophil counts remain poorly understood. Genetic immune dysregulation has not been proven in vivo. Abscess formation in vaccinated Waldenström's macroglobulinemia patients highlights impaired antibody response. Splenic involvement and opsonization defects, similar to multiple myeloma, may predispose to infections with encapsulated organisms. Ensuring infection resolution and determining optimal vaccination frequency is crucial.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter Resident and Medical Student Day, May 2, 2025, Troy, MI

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