Q: Isn’t some unusual or suspicious there is no fever just pain in lower neck mild on off A: I now have enough information to give a thorough, well-grounded answer. Let me compile all the findings: --- Analysis: Mr. Bhuwan Goswami, 23M - Cervical Lymphadenopathy WITHOUT Fever Your suspicion is entirely valid. The absence of fever in a young man with progressive, bilateral cervical lymphadenopathy actually makes this MORE concerning, not less. Here is why: --- What the Reports Show Neck Ultrasound - Progressive Lymphadenopathy: Date Largest Node Levels --------- March 2026 7.2 mm short axis Bilateral II, III, right IB/IVA/V, left IA July 2026 17.8 x 8.8 mm at level II Multiple cervical levels The node more than doubled in size in 4 months. That rate of progression matters. Blood Results July 2026: - CBC: Completely normal - Hb 15.1, WBC 4.72, Neutrophils 50%, Lymphocytes 38%, Platelets 260, ESR only 5 very low - CRP: 0.9 mg/L normal, 5 - Calcium: 10.7 mg/dL - HIGH normal 8.4-10.2 - ALT: 59 U/L - slightly elevated normal up to 41 - Albumin: 5.0 g/dL - slightly high - Chloride: 97 mmol/L - slightly low - Creatinine: 0.83 low for a young male, eGFR 126 fine - Thyroid FT3, FT4, TSH: All completely normal - Coagulation PT/INR, APTT: Normal - Hepatitis B & C: Non-reactive - Uric acid: 6.1 upper-normal range --- Why No Fever Is Actually Suspicious In reactive lymphadenopathy infection, viral illness, you expect: - Fever and sore throat - Elevated WBC, CRP, ESR - Tender nodes - Resolution within 2-6 weeks This patient has none of those features, yet the nodes are growing. Low ESR 5 and normal CRP with enlarging lymph nodes actually points AWAY from infection and TOWARD certain non-infectious diagnoses. --- The Most Important Differentials to Rule Out 1. Hodgkin Lymphoma HIGH PRIORITY - Classic presentation: Young male, 15-35 years, painless rubbery cervical lymphadenopathy - Fever, night sweats, weight loss B symptoms are absent in early disease - their absence does NOT rule it out - The nodes at levels II-V are exactly the cervical chain pattern of Hodgkin - Normal CBC and low ESR can be seen early - The slight calcium elevation adds concern hypercalcemia occurs in some lymphomas via PTHrP or 1,25-OH vitamin D - As Fischer's Mastery of Surgeryhttps://www.ncbi.nlm.nih.gov/books/ states: "Most patients present with asymptomatic, firm, rubbery cervical lymphadenopathy... systemic symptoms may NOT be present" 2. Sarcoidosis IMPORTANT - Can cause bilateral cervical lymphadenopathy WITHOUT fever - The elevated calcium 10.7 fits perfectly - sarcoid macrophages produce excess 1,25-dihydroxyvitamin D causing hypercalcemia - Mild liver enzyme elevation ALT 59 also fits - hepatic sarcoid - Often presents in young adults with minimal or no symptoms 3. Non-Hodgkin Lymphoma - Less common at this age but possible - Painless progressive lymphadenopathy, often afebrile 4. Infectious Mononucleosis less likely now - Would expect positive monospot / EBV antibodies, elevated lymphocytes, splenomegaly - Typically resolves - but has persisted 4 months, making this less likely 5. TB Lymphadenitis Scrofula - Painless cervical lymphadenopathy is the most common extrapulmonary TB presentation - Can be present without fever, especially in early/subacute disease - Would need Mantoux/tuberculin test, IGRA Quantiferon, and node biopsy/FNAC --- The Most Concerning Combination Here The triad of: 1. Progressive bilateral cervical lymphadenopathy 7mm → 17.8mm in 4 months 2. Elevated serum calcium 10.7 3. Normal ESR and CRP arguing against infection ...in a 23-year-old male is a RED FLAG pattern that should prompt urgent investigation for lymphoma or sarcoidosis. --- What Needs to Be Done Urgently Investigation Reason ------ FNAC or excisional lymph node biopsy Single most important test - histology/flow cytometry will diagnose lymphoma, TB, sarcoid CT chest/abdomen/pelvis with contrast Look for mediastinal adenopathy Hodgkin, hilar adenopathy sarcoid, other nodal groups LDH Lactate Dehydrogenase Elevated in lymphoma - not in the current panel Serum PTH and PTHrP Evaluate hypercalcemia cause - PTH should be suppressed if PTHrP or sarcoid 25-OH Vitamin D and 1,25-OH Vitamin D 1,25-OH elevated in sarcoidosis ACE Angiotensin Converting Enzyme level Elevated in 60% of active sarcoidosis Serum Protein Electrophoresis SPEP Rule out plasma cell disorders EBV/CMV serology IgG/IgM If not done Quantiferon-TB Gold / Mantoux Rule out TB Peripheral blood flow cytometry If lymphoma suspected --- Bottom Line No, this is NOT normal and your suspicion is correct. Cervical lymph nodes that keep growing over 4 months in a young man, with no fever, no infection markers, but with elevated calcium - this clinical picture demands a lymph node biopsy before anything else. The most urgent diagnosis to rule out is Hodgkin lymphoma, followed by sarcoidosis and TB. The patient should be referred urgently to a hematologist or surgical oncologist for expedited biopsy. The reassuring CBC and normal blood counts do NOT rule out early lymphoma. Disclaimer: This is educational analysis only and not a substitute for clinical consultation. The treating physician must evaluate and manage this case in person. Q: Can we consider fnac A: Harrison's gives a very direct answer on this exact question. Here is the full picture: --- FNAC for This Case - Yes, But With Important Caveats What Harrison's Principles of Internal Medicine Says Directly "Fine-needle aspiration should not be performed as the first diagnostic procedure. Most diagnoses require more tissue than such aspiration can provide, and it often delays a definitive diagnosis." - Harrison's Principles of Internal Medicine, 22nd Edition 2025 This is specifically in the context of a patient with cervical lymphadenopathy where malignancy is suspected. Harrison's goes on to say: if no mucosal lesion is detected, an excisional biopsy of the largest node should be performed. --- Why FNAC Falls Short for This Specific Patient Limitation Why It Matters Here ------ Cannot preserve nodal architecture Hodgkin lymphoma diagnosis depends on seeing Reed-Sternberg cells within the nodal architecture - FNAC destroys this context Cannot do flow cytometry properly You need adequate cell numbers and viability; FNAC yields are often insufficient False negatives are common A negative FNAC does NOT rule out lymphoma - sensitivity 60-70% for Hodgkin Cannot subtype lymphoma Even if malignant cells are seen, exact lymphoma subtype needed for treatment planning requires core or excisional biopsy Can delay diagnosis If FNAC is non-diagnostic or shows "reactive" changes, clinicians often repeat it rather than proceeding to biopsy - costing weeks --- When FNAC IS Useful FNAC is a reasonable starting point if you suspect: - TB lymphadenitis - AFB smear, culture, and TB-PCR can be done on aspirate; very useful - Metastatic carcinoma - cytology can confirm malignant cells from a known primary - Reactive lymphadenopathy - to reassure and avoid surgery temporarily So if TB is high on the list for this patient which it should be in India, FNAC is still worth doing - ask the lab to send aspirate for AFB smear, TB-PCR GeneXpert, and culture in addition to routine cytology. --- The Recommended Approach for This Patient Given that this is a 23-year-old with 4 months of progressive bilateral cervical nodes, elevated calcium, and no infection markers, the priority order should be: 1. FNAC first it is quick, cheap, and minimally invasive - Send for: cytology + TB-PCR/AFB + culture - If it shows Reed-Sternberg cells or malignant lymphocytes: confirm with excisional biopsy - If it shows granulomas: think TB or sarcoid, add ACE level and Mantoux/IGRA - If it shows reactive changes or is non-diagnostic: do NOT stop here 2. Core needle biopsy or excisional biopsy if FNAC is non-diagnostic - Excisional biopsy of the largest node at level II 17.8mm is the gold standard - Send for histopathology + immunohistochemistry CD15, CD30, CD20, CD3, etc. + flow cytometry 3. CT chest/abdomen/pelvis run in parallel - does not wait for biopsy - Mediastinal adenopathy on CT would strongly push toward Hodgkin or sarcoidosis - Also get LDH and serum ACE levels before the procedure --- Practical Recommendation Yes, do the FNAC - but plan for excisional biopsy in the same conversation with the patient. If the FNAC comes back non-diagnostic or "reactive," the next step must be excisional biopsy without delay. Given the 4-month progression and elevated calcium, this case should not be managed with "watch and wait" after a non-diagnostic FNAC. Disclaimer: This is educational analysis only. Clinical decisions must be made by the treating physician based on a full clinical examination.
