What does the patient’s initial presentation suggest to you?
Frits van Rhee, MD, PhD, University of Arkansas for Medical Sciences, says this is a patient who presents with fever and generalized lymphadenopathy. First, one would think of lymphoma. Other possibilities are infections, such as Epstein-Barr Virus infection or an autoimmune disorder.
Guess the Diagnosis: Case 1
Lisa B. is a 47-year-old female store owner from St. Louis, with a 10-month history of fatigue, night sweats, and weight loss.
- She presents to her PCP with generalized lymphadenopathy, most prominent in the cervical region; there is no polyneuropathy, and patient does not report joint pain. She is referred to a hematologist to rule out lymphoma
- Medical history is unremarkable; family history relevant for a mother with systemic lupus erythematous and father who died with prostate cancer at 65 years old
- Her physical exam is notable for bilateral cervical lymphadenopathy (1-2 cm), mild splenomegaly, and mild edema
- Laboratory findings: anemia (Hgb 11 gm/dL), elevated CRP (35 mg/L) and ESR (80mm/hr), elevated platelets (400,000/mK), Igs (IgG: 4500 mg/dL, IgM: 1500 mg/dL, IgA: 300mg/dL)
- PET scan showed generalized lymphadenopathy with a maximum SUV of 4.5; FNA of the lymph node is uninformative; she was referred to a general surgeon for excisional lymph node biopsy
Lisa’s pathology report shows the following findings:
- Regressed germinal centers, scattered hyperplastic follicles, preserved architecture with patent peripheral sinuses and florid interfollicular plasmacytosis with no light chain restriction
- Prominent vascularization and hyalinization is present
In view of these findings, the hematologist orders further tests, which yield the following results:
- Lymph node: negative EBER, LANA-1, and IgG4 stains; negative PCR for B-cell clonality
- Additional laboratory work: negative ANA, negative dsDNA, anti-Smith and anti-phosholipid antibodies; monospot negative