CERVICAL ACTINOMYCOSIS IN SYSTEMIC LUPUS ERYTHEMATODES, NEPHROCALCINOSIS AND DISTAL RENAL TUBULAR-ACIDOSIS (TYPE-1 RTA)

History and clinical findings: A 25-year-old woman presented with a pa inful soft-tissue swelling in the right neck, which made it impossible to assess the right cervical lymphy nodes, while other lymph nodes we re unremarkable on palpation. For 9 years she had been known to have p olyarthritis. 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. Investigations: Erythrocyt e sedimentation rate was 44 mm/h, there was a leucocytosis of 16 000 g ranulocytes/ml. There was hypokalaemia (3.5 mEq/l) and a metabolic hyp erchloraemic acidosis with a pH of 7.27 and a urinary pH of 6.5. Antin uclear and anti-ds-DNA antibodies were raised (ANA: 3.9 multiple of cu toff point [MOC; normal: 0-1.0]; anti-ds-DNA antibodies: 4.0 [normal: 0-1.0])- Fine needle aspiration cytology from the swelling revealed er ythrocytes, double-refractory horny lamellae, cellular debris and only a few inflammatory cells. Abdominal ultrasound showed nephrocalcinosi s. Microbiological cultures were negative. Diagnosis, treatment and co urse: Assuming a bacterial cause of the swelling antibiotic treatment with Phenoxymethylpenicilline (4 MU/d) was initiated. The local findin gs rapidly improved and the inflammatory parameters regressed to norma l. 16 weeks after the initial admission the abscess recurred and biops y now revealed actinomycetes with typical granules, confirming cervica l 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 acidosi s. Conclusions: This case illustrates the basic approach of establishi ng an all-encompassing diagnosis that brings together seemingly isolat ed findings. It is especially in systemic disease that such diagnostic strategy will frequently lead to its recognition.