Suspicious Lymphadenopathy

Pt with h/o HIV presents with new onset lymphadenopathy. Reports fevers, night sweats, unintended weight loss, recent travel, and unprotected sexual contact. Recent exposure to tuberculosis, cats, and ticks. Firm, fixed supraclavicular lymph node > 2 cm in diameter and HSM on exam.

• Labs

  • CBC with manual differential shows cytopenia and lymphoblasts

  • Obtain ESR, CPR, tuberculosis skin titer, Lyme serology, HIV ELISA

  • Consider rapid strep test (GAS), heterophile Ab (EBV), B. henselae serology, anti-neutrophil antibody (Lupus), gonorrhea/chlamydia NAAT, RPR (syphilis)

• CXR shows mediastinal/hilar mass

• Intervention

  • Concerning s/sx: Refer for early lymph node biopsy

  • No concerning s/sx

    • Consider treatment with antibiotics based on index of suspicion

    • Reevaluate in one month and biopsy if no size reduction is observed

• Pt advised to [anticipatory guidance]

Notes

• Concerning features above are in bold

• Presence of HSM suggests disseminated lymphadenopathy

• Refer pediatric patients for biopsy for supraclavicular nodes, multiple nodes > 3 cm, or a single node > 4 cm

• Do not treat with glucocorticoids before establishing a definitive diagnosis