A 26-year-old man comes to the office after discovering a nontender lump on his neck while taking a shower. The patient has occasional heartburn and takes over-the-counter esomeprazole several times a week. He otherwise feels well and considers himself healthy. The patient has been sexually active with a single female partner over the last year. He has no history of recent travel and no pets. The patient has a 5-pack-year smoking history. He also smokes marijuana most days and drinks alcohol on the weekends. Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 12/min. BMI is 20 kg/m². Oropharyngeal examination shows a 2-cm white plaque on his right inner cheek that is easily scraped off with a tongue depressor, revealing underlying hyperemia. A 2.5-cm mildly tender anterior cervical node is palpated on the right side along with several bilateral,

Question

A 26-year-old man comes to the office after discovering a nontender lump on his neck while taking a shower. The patient has occasional heartburn and takes over-the-counter esomeprazole several times a week. He otherwise feels well and considers himself healthy. The patient has been sexually active with a single female partner over the last year. He has no history of recent travel and no pets. The patient has a 5-pack-year smoking history. He also smokes marijuana most days and drinks alcohol on the weekends. Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 12/min. BMI is 20 kg/m². Oropharyngeal examination shows a 2-cm white plaque on his right inner cheek that is easily scraped off with a tongue depressor, revealing underlying hyperemia. A 2.5-cm mildly tender anterior cervical node is palpated on the right side along with several bilateral, <1-cm, rubbery submandibular nodes. No skin lesions are present. Cardiopulmonary auscultation reveals clear lung fields and normal heart sounds. The abdomen is soft and nontender, and neurologic examination is normal. Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This young patient has submandibular and cervical lymphadenopathy and a white oral plaque easily removed with scraping, suggesting oropharyngeal candidiasis (thrush). Candida species are normal human commensals of the gastrointestinal and genitourinary tracts that may cause mucocutaneous infections (eg, vulvovaginitis) when local microbial balance is disrupted or cellular immunity is impaired. Oral infections are rare in young patients but may be associated with antibiotics, inhaled corticosteroids, or systemic chemotherapy. In the absence of these medications (or if risk factors for HIV are present), oropharyngeal thrush should prompt investigation for HIV infection. This patient requires fourth-generation HIV testing (p24 antigen and HIV-1/HIV-2 antibody) and a potassium hydroxide preparation (or Gram stain) of the mucosal scraping to confirm Candida. (Choice A) Lymph node biopsy is an invasive procedure typically reserved for the diagnosis of malignancy or infection after an extensive workup (eg, laboratory testing, imaging) is performed. Although this patient with a 5-pack-year history of tobacco use is at increased risk of oral malignancy, oral cancer is not typically removed with scraping and would require lesional (not lymph node) biopsy for diagnosis. (Choice C) Amoxicillin is commonly used for upper respiratory bacterial infections including tonsillitis. This patient has a single buccal mucosal lesion that is easily scraped off, likely indicating Candida (fungal) infection. Testing for Candida and HIV should not be delayed. (Choice D) Heterophile antibody testing can diagnose Epstein-Barr virus, which can cause infectious mononucleosis. Patients typically have fever, pharyngitis, lymphadenopathy, and fatigue. With a single buccal lesion and focal lymphadenopathy, this patient is unlikely to have infectious mononucleosis. (Choice E) Drug reactions can sometimes cause oral ulcerations; however, esomeprazole does not typically cause oral lesions, and a single buccal lesion would be atypical. Educational objective: Oral candidiasis typically causes white lesions on the oral mucosa that are easily removed with scraping. Patients with oral candidiasis and no history of recent antibiotics, inhaled corticosteroids, or systemic chemotherapy should be evaluated for HIV infection with a fourth-generation HIV test (p24 antigen and HIV-1/HIV-2 antibody).

A 26-Year-Old Man Comes to the Office After Discovering a Nontender