Clinical Analysis: Persistent Cervical Lymphadenopathy - Mr. Bhuwan Goswami (23M)

What the Reports Show

What This Pattern Means Clinically

• Progressive enlargement over 4 months (not resolving)
• Multiple cervical levels involved bilaterally
• Node size now >17 mm long axis / 8.8 mm short axis
• Duration >6 weeks (now 4+ months) without explanation

Differential Diagnosis (Most to Least Likely in 23-year-old Indian Male)

1. Tuberculous (TB) Adenitis - HIGH PRIORITY

• Most common cause of chronic cervical lymphadenopathy in young adults in India
• Typically affects deep upper cervical nodes (level II is most commonly affected)
• Can be bilateral and multilevel
• Nodes are often painless, may feel firm or rubbery
• A pulmonary focus must always be excluded
• Bailey and Love's Surgery: "This condition most commonly affects children or young adults... The deep upper cervical nodes are most commonly affected... a primary focus in the lungs must always be suspected."

2. Hodgkin Lymphoma - MUST EXCLUDE URGENTLY

• Classic presentation: adolescents and young adults, more common in males - this matches perfectly
• Painless, firm, rubbery cervical nodes (often levels II, III, IV) are the hallmark
• Associated with EBV
• "B symptoms": fever, night sweats, unintentional weight loss
• K.J. Lee's Essential Otolaryngology: "Malignancy of lymphoreticular system associated with Epstein-Barr virus. Adolescents and young adults... More common in males. Presents as cervical and supraclavicular neck mass."
• Excisional biopsy is the gold standard - Reed-Sternberg cells confirm diagnosis

3. Non-Hodgkin Lymphoma

• Less common than Hodgkin's in this age group
• Often painless lymphadenopathy; may progress rapidly

4. Infectious Mononucleosis (EBV)

• Usually self-limited but can cause prolonged lymphadenopathy
• More likely if there was a prodrome of pharyngitis, fever, fatigue

5. Reactive / Non-specific Lymphadenopathy

• Less likely given 4-month duration and progressive growth
• Usually bilateral and seen after throat/respiratory infections

6. Other Infections

• Toxoplasmosis, CMV, HIV, cat-scratch disease (Bartonella), fungal

What Needs to Be Done NOW

Immediate Investigations

• Complete blood count with differential (CBC) - look for lymphocytosis, abnormal cells
• ESR, CRP (inflammation markers)
• LDH (elevated in lymphoma)
• Monospot / EBV serology, CMV IgM/IgG
• Mantoux (tuberculin) test or IGRA (QuantiFERON-TB Gold)
• HIV test
• ANA, serum protein electrophoresis
• Liver function tests

• Chest X-ray - look for mediastinal widening (lymphoma) or pulmonary TB
• CT neck + chest + abdomen with contrast - full nodal mapping, mediastinal assessment, organ involvement
• CT is preferred over plain ultrasound for staging purposes

• Fine Needle Aspiration Cytology (FNAC) of the largest node (17.8 mm at level II) - first step, quick and minimally invasive; can guide further workup
• If FNAC is inconclusive or lymphoma is suspected: Excisional lymph node biopsy (the largest, firmest node) - mandatory for lymphoma diagnosis, as FNAC cannot determine lymph node architecture
• Fischer's Mastery of Surgery: "FNA does not provide information regarding cell structure and is inadequate for ruling out certain malignancies including lymphoma... Excisional lymph node biopsy is often required for adequate diagnosis of malignancy."

Referral

1. ENT specialist / Head & Neck Surgeon (primary referral for cervical lymphadenopathy workup)
2. Haematologist or Medical Oncologist if lymphoma features are confirmed

Summary for the Patient

Disclaimer: This is an educational analysis based on the imaging reports provided. It does not replace a clinical examination or a physician's assessment. Please consult a qualified doctor promptly for proper evaluation and management.