A 17-year-old boy comes to the office due to fatigue. For the past 6 weeks, the patient has had difficulty attending evening soccer practice due to excessive tiredness and feverishness. He has also had generalized itching but no rash. The patient has no nasal congestion, sore throat, cough, dyspnea, abdominal pain, or diarrhea. He has no significant medical history and takes no medications. Temperature is 38 C (100.4 F), blood pressure is 118/66 mm Hg, and pulse is 86/min. Physical examination shows no scleral icterus or conjunctival pallor. There are several enlarged, nontender, and firm cervical and supraclavicular lymph nodes. Oropharyngeal mucosa and tonsils are normal. The lungs are clear on auscultation, and heart sounds are normal. The abdomen is soft and nontender with no organomegaly. There is no extremity edema or skin rash. Which of the following is most appropriate to establish a diagnosis for this patient?

Question

A 17-year-old boy comes to the office due to fatigue.  For the past 6 weeks, the patient has had difficulty attending evening soccer practice due to excessive tiredness and feverishness.  He has also had generalized itching but no rash.  The patient has no nasal congestion, sore throat, cough, dyspnea, abdominal pain, or diarrhea.  He has no significant medical history and takes no medications.  Temperature is 38 C (100.4 F), blood pressure is 118/66 mm Hg, and pulse is 86/min.  Physical examination shows no scleral icterus or conjunctival pallor.  There are several enlarged, nontender, and firm cervical and supraclavicular lymph nodes.  Oropharyngeal mucosa and tonsils are normal.  The lungs are clear on auscultation, and heart sounds are normal.  The abdomen is soft and nontender with no organomegaly.  There is no extremity edema or skin rash.  Which of the following is most appropriate to establish a diagnosis for this patient?

Quizplus · Accepted Answer

11ec25c8_d41d_4e78_bc81_9fc596e169d4_MD0003_00 This young patient's subacute fever, pruritus, fatigue, and painless cervical and supraclavicular lymphadenopathy (LAD) raise strong suspicion for Hodgkin lymphoma (HL). Cases generally arise in a bimodal distribution, with peak incidence in patients age 15-35 and >60. HL usually arises in a single lymph node and disseminates to contiguous nodes via the lymphatic and thoracic ducts. Patients generally present with painless peripheral LAD, particularly in the cervical and supraclavicular chains. Significant mediastinal LAD also occurs in ~50% of cases and may lead to cough, shortness of breath, or chest pain. Most patients have long-standing B symptoms (eg, fever, night sweats, weight loss) and pruritus (a paraneoplastic process classically associated with HL and likely due to cytokine and interleukin release). Individuals with unexplained LAD and findings concerning for malignancy (eg, supraclavicular LAD) require excisional lymph node biopsy. Malignant Reed-Sternberg cells admixed with nonneoplastic inflammatory cells are diagnostic of HL. Reed-Sternberg cells (Choice A) Antinuclear antibodies are elevated in systemic lupus erythematosus (SLE), which can cause fatigue, fever, and painless peripheral LAD in the cervical, axillary, or inguinal chains. However, supraclavicular LAD is quite uncommon and strongly suggests malignancy. In addition, this patient has no diagnostic features of SLE (eg, malar rash, arthralgia, serositis). (Choice C) Heterophile antibody testing can diagnose infectious mononucleosis, which often causes fatigue, fever, and peripheral LAD (primarily in the cervical chain). However, most patients have sore throat and evidence of pharyngitis on examination, and almost all cases resolve within a month. In addition, LAD tends to be tender (not nontender), and splenomegaly is common. (Choice D) Rapid plasma reagin testing can assist in the diagnosis of syphilis. Secondary syphilis often causes painless peripheral LAD (characteristically in the epitrochlear nodes). However, supraclavicular LAD is uncommon, and most patients have a diffuse, symmetric maculopapular rash that includes the palms and soles. (Choice E) Erythropoietin level testing is part of the diagnostic workup for polycythemia vera, which is a chronic myeloproliferative disorder associated with elevated red blood cell mass. Although this disease is often associated with aquagenic pruritus (itching with warm water exposure), LAD does not generally occur. In addition, most cases occur in patients age >60. (Choice F) Tuberculin skin testing can identify those who have been exposed to tuberculosis. Although tuberculosis lymphadenitis is a common cause of painless peripheral LAD in developing countries, it is uncommon in the United States. In addition, fever is somewhat uncommon, pruritus is atypical, and this patient has no risk factors for exposure (eg, incarceration, travel to an endemic region). Educational objective: Hodgkin lymphoma often presents with painless peripheral lymphadenopathy (LAD) in the cervical and/or supraclavicular chains. Patients may also have mediastinal LAD, B symptoms, and pruritus. Diagnosis is usually made with excisional lymph node biopsy (Reed-Sternberg cells).

A 17-Year-Old Boy Comes to the Office Due to Fatigue