A 25-year-old Caucasian man comes to see you in the office because of persistent "lumps" in the neck. He recalls an episode of marked fatigue, fever, pharyngitis, and generalized lymphadenopathy about
8-10 weeks ago, when he was diagnosed with infectious mononucleosis. Most of his symptoms except the neck "lumps" resolved completely in two weeks. On physical examination, he has three anterior cervical lymph nodes, the largest being 2 cm x 2 cm in size. They are mobile and have a firm rubbery consistency. The patient denies any associated symptoms, and the rest of his physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Question

A 25-year-old Caucasian man comes to see you in the office because of persistent "lumps" in the neck. He recalls an episode of marked fatigue, fever, pharyngitis, and generalized lymphadenopathy about
8-10 weeks ago, when he was diagnosed with infectious mononucleosis. Most of his symptoms except the neck "lumps" resolved completely in two weeks. On physical examination, he has three anterior cervical lymph nodes, the largest being 2 cm x 2 cm in size. They are mobile and have a firm rubbery consistency. The patient denies any associated symptoms, and the rest of his physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: Infectious mononucleosis is a viral illness caused by the Epstein-Barr virus. It classically presents with marked fatigue, fever, tonsillar pharyngitis, and generalized lymphadenopathy. Acute symptoms usually resolve in one to two weeks. The infection is usually seen in adolescents and young adults, although most of them are asymptomatic. Lymphadenopathy is typically symmetric, and usually involves posterior cervical nodes. It peaks in the first week of infection, and subsides over the next 2-3 weeks. Patients with localized lymphadenopathy can be observed for 3-4 weeks. A biopsy should be performed if the abnormal nodes fail to resolve after that time, or earlier, if there are other signs of malignancy. Abnormal and persistent lymphadenopathy is sometimes the first clinical manifestation of an underlying lymphoma. This patient should be referred to a surgeon for a node biopsy. (Choice B) Empiric treatment of unexplained lymphadenopathy is not indicated. (Choice C) Hard cervical nodes, especially in older patients and in smokers, are suggestive of a malignancy. These patients should be referred to an otolaryngologist for fiberoptic examination of the oropharynx to look for a primary malignancy. (Choice D) A chest x-ray is an insensitive study and has a low yield in the absence of any specific clinical features. (Choice E) Patients with localized lymphadenopathy should be observed for three to four weeks. A biopsy should be performed if the abnormal nodes fail to resolve after four weeks. Educational Objective: Persistent and localized abnormal lymph nodes should be biopsied.

A 25-Year-Old Caucasian Man Comes to See You in the Office Because of