Clinical Scenario:
A 12-year-old boy presents with a 5-week history of a gradually enlarging swelling on the left side of the neck. He has completed two courses of oral antibiotics without improvement. There is no history of sore throat, dental infection, cat scratch, or recent upper respiratory tract infection.
On examination, a 3 × 2 cm left lower cervical lymph node and a 2 cm supraclavicular lymph node are palpable. The nodes are firm, rubbery, discrete, non-tender, and freely mobile. The overlying skin is normal. There is no fluctuation or sinus formation. Mild splenomegaly is present.
What is the most likely diagnosis?
A. Acute bacterial lymphadenitis
B. Hodgkin lymphoma
C. Tuberculous lymphadenitis
D. Infectious mononucleosis
E. Cat-scratch disease
Correct answer & Explanation:
Correct Answer: B. Hodgkin lymphoma
Explanation
This child has several clinical features that strongly suggest Hodgkin lymphoma rather than an infectious cause of cervical lymphadenopathy.
The key findings are:
- Persistent lymphadenopathy (>4–6 weeks)
- Failure to respond to appropriate antibiotics
- Firm, rubbery, discrete, non-tender lymph nodes
- Supraclavicular lymph node involvement
- Mild splenomegaly
- Absence of an obvious local source of infection (e.g., pharyngitis, dental infection, scalp infection)
In children and adolescents, Hodgkin lymphoma most commonly presents with painless cervical lymphadenopathy, often involving the lower cervical and supraclavicular lymph nodes. The lymph nodes are typically firm, rubbery, and discrete, and the overlying skin remains normal. Although constitutional (“B”) symptoms such as fever, night sweats, and weight loss may occur, they are not required for the diagnosis.
The diagnosis is confirmed by excisional lymph node biopsy, which demonstrates Reed–Sternberg cells in classical Hodgkin lymphoma.
Why the other options are incorrect
A. Acute bacterial lymphadenitis
Usually presents with an acute onset of painful, tender lymph nodes associated with fever and erythema of the overlying skin. Most children improve with appropriate antibiotic therapy.
B. Hodgkin lymphoma
Correct. Persistent, painless, firm, rubbery cervical and supraclavicular lymphadenopathy that does not respond to antibiotics is highly suggestive of Hodgkin lymphoma.
C. Tuberculous lymphadenitis
Typically presents with chronic, painless cervical lymphadenopathy, but the nodes are more commonly matted, may become fixed to surrounding tissues, and can later develop fluctuation or discharging sinuses. Constitutional symptoms may be present, and a history of tuberculosis exposure may be elicited.
D. Infectious mononucleosis
Usually presents with fever, pharyngitis, fatigue, and bilateral posterior cervical lymphadenopathy. The lymph nodes are generally tender, and hepatosplenomegaly may be present.
E. Cat-scratch disease
Usually follows a history of cat exposure and presents with a single tender regional lymph node, most commonly in the axillary or cervical region. The illness is generally self-limited.
Learning Point
Clinical features that should raise suspicion for Hodgkin lymphoma in a child with cervical lymphadenopathy include:
- Persistent lymph node enlargement for more than 4–6 weeks
- Firm, rubbery, non-tender, discrete lymph nodes
- Supraclavicular lymph node involvement
- Lack of response to appropriate antibiotic therapy
- Hepatosplenomegaly or splenomegaly
- Constitutional (B) symptoms, when present
An excisional lymph node biopsy is the gold standard for establishing the diagnosis.
