A 26-year-old woman comes to the physician because of a constant dry cough, low grade fevers, and night sweats for the last 4 weeks. She initially attributed her symptoms to a respiratory infection, but they have been progressively worsening. She denies shortness of breath or chest pain. Furthermore, she has lost approximately 5 lbs (2.3 kg) over the past 4 weeks. She denies any other medical problems and takes no medications with the exception of over-the-counter cough syrup. She denies recent travel or sick contacts. She does not use tobacco, alcohol, or illicit drugs.
Her temperature is 100.4 F (38.0 C), blood pressure is 110/80 mm Hg, and pulse is 90/min. Physical examination shows multiple, bilateral, firm, rubbery, 2 to 3 cm-sized lymph nodes in the cervical, supraclavicular, and axillary region. Cardiopulmonary examination is unremarkable. There is no hepatosplenomegaly.
Chest imaging shows a widened mediastinum, hilar fullness, and clear lungs. HIV and heterophile antibody testing is negative.
Which of the following is the most appropriate next step in management?

Question

A 26-year-old woman comes to the physician because of a constant dry cough, low grade fevers, and night sweats for the last 4 weeks.  She initially attributed her symptoms to a respiratory infection, but they have been progressively worsening.  She denies shortness of breath or chest pain.  Furthermore, she has lost approximately 5 lbs (2.3 kg) over the past 4 weeks.  She denies any other medical problems and takes no medications with the exception of over-the-counter cough syrup.  She denies recent travel or sick contacts.  She does not use tobacco, alcohol, or illicit drugs.
Her temperature is 100.4 F (38.0 C), blood pressure is 110/80 mm Hg, and pulse is 90/min.  Physical examination shows multiple, bilateral, firm, rubbery, 2 to 3 cm-sized lymph nodes in the cervical, supraclavicular, and axillary region.  Cardiopulmonary examination is unremarkable.  There is no hepatosplenomegaly.
Chest imaging shows a widened mediastinum, hilar fullness, and clear lungs.  HIV and heterophile antibody testing is negative.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_982a_01b3_853d_63b82874ecca_MD0002_00 The presence of B symptoms (eg, fevers, night sweats, weight loss), generalized lymphadenopathy with firm lymph nodes >2 cm, supraclavicular node involvement, and abnormal chest x-ray findings are worrisome features for malignancy (lymphoma) and should prompt further work-up. Lymphadenopathy can be localized (limited to one anatomic site) or generalized (≥2 non-contiguous anatomic areas involved): Generalized: All patients with generalized lymphadenopathy should have a CBC with differential and a chest x-ray. If these are normal, additional testing may be performed including RPR, HIV, ANA, HBsAg, PPD, and heterophile testing, although these tests are often low yield. If the diagnosis continues to be uncertain, a lymph node biopsy should be performed. Localized: In patients with unexplained localized lymphadenopathy and a reassuring clinical picture, a 3- to 4-week period of observation is appropriate. Biopsy should be performed if an abnormal node has not resolved after four weeks and/or there are other findings suggesting malignancy. Once biopsy has been chosen, ideally the largest, most suspicious, and most accessible node is selected. If no single node predominates, the choices in descending order in regards to diagnostic yield are supraclavicular, cervical, axillary, and inguinal nodes. Finally, an excisional biopsy of an intact node is preferred as it is more accurate, of higher yield, and allows sufficient tissue for histopathological, immunological, and molecular biological assessment. (Choice A) Core needle biopsy is generally reserved for patients with suspected lymphoma in whom an intact node is not easily accessible (eg, retroperitoneal nodes). (Choice C) Fine needle aspiration (FNA) for cytology is most useful when searching for recurrence of cancer. It is less accurate and of lower yield than an excisional biopsy, especially in the initial diagnosis of lymphoma. (Choice D) Lymphoma is statistically more likely than tuberculosis (TB) in this patient. Bronchoscopy is invasive, and lymph node biopsy and histology can also diagnose TB. (Choice E) Usually, the most accessible node is chosen for biopsy. Mediastinoscopy and biopsy is significantly more invasive than excisional biopsy of the peripheral nodes. Educational objective: Biopsy should be performed if an abnormal node has not resolved after four weeks, there are findings suggesting malignancy, or generalized lymphadenopathy of uncertain etiology is present. An excisional biopsy of an intact node is preferred. Ideally, the largest, most suspicious, and most accessible node is selected; but if no single node predominates, the choices in descending order in regards to diagnostic yield are supraclavicular, cervical, axillary, and inguinal. __________ References: Lymphadenopathy: Differential Diagnosis and Evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/9803196) Lymphadenopathy and Malignancy (http://www.ncbi.nlm.nih.gov/pubmed/12484692)

A 26-Year-Old Woman Comes to the Physician Because of a Constant