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LETTER TO EDITOR
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 50-51

Disseminated lymphadenopathy: Time is the best diagnostician


Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission27-Dec-2018
Date of Decision29-Dec-2018
Date of Acceptance29-Dec-2018
Date of Web Publication18-Feb-2019

Correspondence Address:
Dr. Pranav Ish
Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJMS.INJMS_43_18

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How to cite this article:
Mengar M, Ish P, Chakrabarti S. Disseminated lymphadenopathy: Time is the best diagnostician. Indian J Med Spec 2019;10:50-1

How to cite this URL:
Mengar M, Ish P, Chakrabarti S. Disseminated lymphadenopathy: Time is the best diagnostician. Indian J Med Spec [serial online] 2019 [cited 2019 Jul 24];10:50-1. Available from: http://www.ijms.in/text.asp?2019/10/1/50/252477

Sir,

Lymphadenopathy is a common clinical presentation in all subspecialties of medicine. It is a cause of concern for the patient and physician alike even in the absence of symptoms due to varied sites, duration, and etiologies. In developing countries like India, tuberculosis is the first differential diagnosis for a patient who presents with chronic lymph node enlargement. Nonetheless, studies have shown that more than 50% of cases are due to nontubercular causes, and, in these cases, excision biopsy with histopathology and/or microbiological examination is the only way to exclude tuberculosis.[1] Other important causes of lymphadenopathy are listed in [Table 1] with suggested investigations for the same.
Table 1: Etiology of disseminated lymphadenopathy with suggested investigations

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A 21-year-old male resident of Delhi, a marketing executive, presented with complaints of dysphagia, swellings in the neck, and fever with chills for 1 week. He had a history of recurrent sore throat and a clinical diagnosis of sinusitis for 5 years. The patient had a history of abdomen pain and fever, 5 years back, when his ultrasound abdomen revealed abdominal lymphadenopathy, and he was empirically treated with anti-tubercular therapy to which his symptoms responded, but the treatment was terminated in 3 months for an unknown reason. On examination, the patient was hemodynamically stable and had erythematous oropharyngeal mucosa with granular appearance and pus plaques over the tonsil. Neck examination revealed multiple enlarged, tender bilateral cervical nodes. There was mild hepatosplenomegaly.

Computed tomography (CT) of paranasal sinuses revealed thickened mucosa in the frontal, ethmoidal, and maxillary sinuses with opaque left maxillary sinus and deviated nasal septum with hypertrophy of inferior turbinate on the right side. CT thorax showed 9 cm × 11 mm subcarinal lymph node and the rest of findings within normal limits. His hematological investigations were suggestive of normal counts with preserved organ function tests. Tuberculin test produced 17 cm × 20 mm induration after 48 h. In view of positive Mantoux, fever, and history of taking incomplete course of anti-tubercular therapy in the past, a clinical diagnosis of tubercular lymphadenopathy was made. However, cervical lymph node fine-needle aspiration was suggestive of reactive lymphadenitis with negative acid-fast bacillus and cartridge-based nucleic acid amplification test. Reviewing the patient's history and asking in detail revealed incidents of unprotected sex with different partners. Further workup was done for etiology, and hepatitis B surface antigen, anti-hepatitis C virus, and HIV by enzyme-linked immunosorbent assay were negative. However, immunoglobulin M (IgM) against Epstein–Barr viral capsid antigen was strongly positive with titer of 21.85, and peripheral smear was suggestive of transformed lymphocytes [Figure 1]. Hence, a diagnosis of infectious mononucleosis was made. The patient had persistent fever not responding to antibiotics for 1 week. With a detailed counseling with the family, the patient's antibiotics were stopped and he was discharged on antipyretics and advised to maintain good hydration and nutrition. In follow-up visits, the patient's lymph nodes decreased in size, fever showed downward trend, and the patient was back to stable baseline state in 2 weeks.
Figure 1: Peripheral smear showing transformed lymphocytes

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Infectious mononucleosis is an acute illness due to Epstein–Barr virus infection, which occurs mainly in adolescents and young adults. It is classically characterized by fever, pharyngitis, fatigue, and lymphadenopathy. Other findings can include splenomegaly and palatal petechiae.[2] Cervical lymphadenopathy tends to involve the posterior chain of lymph nodes. Suspected cases should have a white blood cell count with differential and a heterophile test based on the history and physical examination.[3] In addition, patients should also have a diagnostic evaluation for streptococcal infection by culture or antigen testing. The vast majority of individuals with primary Epstein–Barr virus infection recover uneventfully and develop durable immunity controlling the latent virus. IgM and IgG antibodies directed against viral capsid antigen have high sensitivity and specificity (97% and 94%, respectively).[4] In most patients, the acute symptoms resolve in 1–2 weeks, although fatigue and poor functional status can persist for months.[5]

Despite having no specific treatment for infectious mononucleosis, supportive therapy is enough for most patients. Thus, one must be prudent enough to take a detailed history, examination, and appropriate investigations to get the correct diagnosis and treatment. In patients with no microbiological evidence of tuberculosis and history or examination suggestive of nontubercular diagnosis, a high index of suspicion must be kept for other infections such as infectious mononucleosis.

In conclusion, our case exemplifies some of the obstacles that can be encountered during the diagnosis of disseminated lymphadenopathy, especially in settings with high burdens of tuberculosis. Furthermore, this case shows how it is important to make a correct diagnosis as treatment has vast variations ranging from drug therapy for tuberculosis over 6 months, drug withdrawal for drug-induced lymphadenopathy, chemotherapy, and radiotherapy for lymphoma and even observation for reactive viral lymphadenitis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Thakkar K, Ghaisas SM, Singh M. Lymphadenopathy: Differentiation between tuberculosis and other non-tuberculosis causes like follicular lymphoma. Front Public Health 2016;4:31.  Back to cited text no. 1
    
2.
Rea TD, Russo JE, Katon W, Ashley RL, Buchwald DS. Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr virus. J Am Board Fam Pract 2001;14:234-42.  Back to cited text no. 2
    
3.
Aronson MD, Komaroff AL, Pass TM, Ervin CT, Branch WT. Heterophil antibody in adults with sore throat: Frequency and clinical presentation. Ann Intern Med 1982;96:505-8.  Back to cited text no. 3
    
4.
Bruu AL, Hjetland R, Holter E, Mortensen L, Natås O, Petterson W, et al. Evaluation of 12 commercial tests for detection of Epstein-Barr virus-specific and heterophile antibodies. Clin Diagn Lab Immunol 2000;7:451-6.  Back to cited text no. 4
    
5.
Buchwald DS, Rea TD, Katon WJ, Russo JE, Ashley RL. Acute infectious mononucleosis: Characteristics of patients who report failure to recover. Am J Med 2000;109:531-7.  Back to cited text no. 5
    


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