A 16-year-old boy is brought to the clinic for evaluation of intermittent fevers. He first noticed symptoms after returning from a rabbit hunting trip in Pennsylvania a month ago. Initially, the fevers occurred every few days; however, for the past 2 weeks, he has had daily temperature spikes ?38.1 C (100.6 F). The patient has been taking acetaminophen daily, which reduces the fevers only temporarily. Since the trip, he has also noticed a swelling above his right collarbone that has enlarged to the size of a quarter. He has no dyspnea, night sweats, or weight loss. The patient has no chronic medical conditions, and immunizations are up to date. He has 3 pet cats at home. He is sexually active and has had 3 lifetime partners. Temperature is 38.3 C (100.9 F). Multiple small right anterior cervical lymph nodes are palpable. The right supraclavicular fossa has a solitary, firm, 2.5-cm (1-in) palpable lymph node. Cardiopulmonary examination is normal. The abdomen is soft with no palpable masses. Biopsy of the lymph node is shown in the exhibit. Which of the following is the most likely diagnosis for this patient?

Question

A 16-year-old boy is brought to the clinic for evaluation of intermittent fevers.  He first noticed symptoms after returning from a rabbit hunting trip in Pennsylvania a month ago.  Initially, the fevers occurred every few days; however, for the past 2 weeks, he has had daily temperature spikes ?38.1 C (100.6 F).  The patient has been taking acetaminophen daily, which reduces the fevers only temporarily.  Since the trip, he has also noticed a swelling above his right collarbone that has enlarged to the size of a quarter.  He has no dyspnea, night sweats, or weight loss.  The patient has no chronic medical conditions, and immunizations are up to date.  He has 3 pet cats at home.  He is sexually active and has had 3 lifetime partners.  Temperature is 38.3 C (100.9 F).  Multiple small right anterior cervical lymph nodes are palpable.  The right supraclavicular fossa has a solitary, firm, 2.5-cm (1-in) palpable lymph node.  Cardiopulmonary examination is normal.  The abdomen is soft with no palpable masses.  Biopsy of the lymph node is shown in the exhibit.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

11ec25c8_d6a3_d292_bc81_73c79a140bf3_MD0003_00 This patient has Reed-Sternberg cells (large, multinucleated lymphocytes) on lymph node biopsy, characteristic of Hodgkin lymphoma (HL), the most common cancer that occurs during late adolescence (age 15-19). HL typically presents with systemic B symptoms (eg, prolonged fever, night sweats, weight loss) and painless, firm lymphadenopathy (though nodes may be tender if rapidly enlarging). Although cervical lymphadenopathy is common with infectious processes, a large supraclavicular node, as seen in this patient, is highly suspicious for malignancy. Chest x-ray is performed to evaluate for a mediastinal mass, which is present in the majority of patients with HL and can lead to compressive symptoms (eg, dysphagia, dyspnea) if it is large. Lymph node biopsy is diagnostic; the presence of Reed-Sternberg cells is specific for HL. With combination chemotherapy, children and adolescents have an excellent prognosis (>85% cure rate). (Choice A) HL is more common among patients with HIV (compared to those without) but is typically associated with prolonged immunosuppression; therefore, it is unlikely to develop concomitantly with acute HIV infection. Furthermore, this patient is unlikely to have acute HIV because, even though acute HIV can cause fever and lymphadenopathy, pharyngitis, rash, and diarrhea are usually also present; in addition, lymphadenopathy in HIV typically involves the axillary, cervical, and occipital nodes. (Choice B) Cat scratch disease (Bartonella henselae) presents with a papular skin lesion, fever, and ?1 enlarged regional lymph nodes. Histopathology shows nonspecific lymphoid hyperplasia and areas of necrosis. necrosis (Choice D) Lyme disease classically presents with erythema migrans rash after a tick bite. Fever may be present, but lymphadenopathy is not typical. This patient's supraclavicular node and lack of rash makes HL more likely. erythema migrans (Choices E and F) Sarcoidosis and tuberculosis (TB) can cause fever, weight loss, and lymphadenopathy, but pulmonary manifestations (eg, cough) are often also present. Biopsy of sarcoidosis shows noncaseating granulomas, whereas biopsy of TB shows caseating granulomas (brackets) and multinucleated giant cells (arrow). sarcoidosis TB Educational objective: Prolonged fever and lymphadenopathy (particularly supraclavicular) are common manifestations of Hodgkin lymphoma. Reed-Sternberg cells on lymph node biopsy are diagnostic. References: Hodgkin lymphoma: pathology and biology. (http://www.ncbi.nlm.nih.gov/pubmed/27496304) Hodgkin lymphoma: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/26541251)

A 16-Year-Old Boy Is Brought to the Clinic for Evaluation