A 37-year-old man comes to the office due to a week of sore throat. He also reports malaise but has had no fever, chills, nasal congestion, cough, or difficulty swallowing. Six months ago, the patient had similar symptoms and was found to have several cervical lymph nodes measuring 1.5-2 cm. Empiric antibiotic therapy was prescribed, and at follow-up 3 weeks later his sore throat had resolved and the lymph nodes were smaller. The patient has a history of hepatitis C for which he received treatment several years ago. He smokes a pack of cigarettes daily and drinks alcohol occasionally.
Temperature is 37.2 C (99 F), blood pressure is 122/68 mm Hg, and pulse is 89/min. There is pharyngeal erythema and mild tonsillar enlargement. Three nontender anterior cervical lymph nodes are palpated, measuring approximately 3 cm each. There is a 0.5-cm right posterior cervical node. The liver span is 10 cm, and the spleen cannot be palpated. Physical examination is otherwise unremarkable.
Complete blood count, including peripheral blood smear, is unremarkable. Testing for HIV and rapid plasma reagin are negative. Symptomatic treatment is advised, and on follow-up 4 weeks later the patient reports his sore throat has resolved. The anterior cervical lymph nodes are decreased in size and now measure 1.5-2 cm.
Which of the following is the most likely cause of this patient's lymphadenopathy?

Question

A 37-year-old man comes to the office due to a week of sore throat.  He also reports malaise but has had no fever, chills, nasal congestion, cough, or difficulty swallowing.  Six months ago, the patient had similar symptoms and was found to have several cervical lymph nodes measuring 1.5-2 cm.  Empiric antibiotic therapy was prescribed, and at follow-up 3 weeks later his sore throat had resolved and the lymph nodes were smaller.  The patient has a history of hepatitis C for which he received treatment several years ago.  He smokes a pack of cigarettes daily and drinks alcohol occasionally.
Temperature is 37.2 C (99 F), blood pressure is 122/68 mm Hg, and pulse is 89/min.  There is pharyngeal erythema and mild tonsillar enlargement.  Three nontender anterior cervical lymph nodes are palpated, measuring approximately 3 cm each.  There is a 0.5-cm right posterior cervical node.  The liver span is 10 cm, and the spleen cannot be palpated.  Physical examination is otherwise unremarkable.
Complete blood count, including peripheral blood smear, is unremarkable.  Testing for HIV and rapid plasma reagin are negative.  Symptomatic treatment is advised, and on follow-up 4 weeks later the patient reports his sore throat has resolved.  The anterior cervical lymph nodes are decreased in size and now measure 1.5-2 cm.
Which of the following is the most likely cause of this patient's lymphadenopathy?

Quizplus · Accepted Answer

11ec193a_9830_4352_853d_5dd231323cc0_MD0002_00 Localized lymphadenopathy (LAD) can be due to infection, rheumatic disease, malignancy, or medications. The underlying etiology can often be determined with a thorough history and physical examination. Initial findings consistent with malignancy include: Supraclavicular LADRapidly progressive LADB symptoms Supraclavicular LAD Rapidly progressive LAD B symptoms Immediate lymph node biopsy should be performed in patients with these features. Patients without these features, particularly if there is a clear inciting cause (eg, upper respiratory infection with cervical lymphadenopathy), can be observed for 3-4 weeks to see if the LAD resolves. Those with persistent LAD require an excisional lymph node biopsy to evaluate for malignancy. Excisional lymph node biopsy is preferred over core needle biopsy or fine-needle aspiration due to higher diagnostic yields. Although this patient's cervical lymphadenopathy initially appeared to be due to an upper respiratory infection, the lymphadenopathy did not resolve with treatment. Months of painless LAD that waxes and wanes but never resolves raises suspicion for an indolent lymphoma (eg, follicular lymphoma), which can present with no other manifestations (eg, splenomegaly, B symptoms, complete blood count abnormalities). (Choice A) Atypical mycobacterial infections tend to present with weeks or months of slowly progressive (not waxing and waning) lymphadenopathy that is matted and fluctuant. (Choice B) Mononucleosis usually causes pharyngitis with a tonsillar exudate and tender cervical lymphadenopathy that lasts 2-3 weeks. In addition, patients usually have malaise, fever, and lymphocytosis. (Choice C) Hepatitis C-related leukocytoclastic vasculitis can occur in conjunction with essential mixed cryoglobulinemia. Patients usually present with lower extremity petechia and palpable purpura, not LAD. (Choice E) Although recurrent group A streptococcal infection can cause recurrent pharyngitis and cervical lymphadenopathy, reactive lymphadenopathy from infection is usually milder (<3 cm). In addition, this patient's sore throat resolved with antibiotic treatment yet the lymphadenopathy persisted. This suggests that infection was not the cause of the lymphadenopathy. Educational objective: Lymphadenopathy can be observed for 3-4 weeks in patients with no signs or symptoms of malignancy; those with persistent lymphadenopathy require excisional lymph node biopsy to evaluate for cancer. Indolent lymphomas often present with months of waxing and waning painless, localized lymphadenopathy without other manifestations. __________ References: Biopsy of peripheral lymph nodes. (http://www.ncbi.nlm.nih.gov/pubmed/7137719) Lymphadenopathy: differential diagnosis and evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/9803196)

A 37-Year-Old Man Comes to the Office Due to a Week