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Should biopsy be done for swollen lymph nodes?

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Posted on Thu, 22 May 2014
Question: Hi,
I've been vomiting every day, all day for almost 3 months now and no specialists have been able to pin it down as my results of GI, OBGYN, NEURO, ENT, PULM, CARDIO, ENDO, have roughly been unremarkable enough to suggest what is happening to me. I have shown dry flushing and other problems suggestive of carcinoid syndrome, but those tests have been negative (even low). My hypothyroid became dangerously overactive-TSH at a .06, but with an alteration of medication, it is now normal and I am still having these symptoms. I had low cortisol, but with the ACTH stimulation test, it showed I did not have adrenal insufficiency. ANA 1:320. MRI (brain) and CT (neck) have shown mild acute sphenoid sinusitis, mild-moderate right internal laryngocele and mild left internal laryngocele at the level of thyrohyoid ligaments and multiple, non-enlarged, non necrotic, mildly enhancing, cervical, supraclavicular, upper mediastinal and partially seen axillary lymph nodes (that RADIO are suggesting are likely benign and reactive). Also, an ENT scope showed "cobblestoning" which was not present during an Endoscopy (2 mos. prior).

Symptoms for entire illness: Vomiting, Hoarseness, Migraines with eye and jaw pain and blurry vision, Tolerable to stabbing abdominal pain, Diarrhea (blood for 2 wks (after clear colonoscopy and pill endoscopy) and found in rectal exam), Fever and chills, Chest Pain (not persistent, dull to sharp), Difficultly swallowing (beginning of illness and recently recurring (3 wks)), Labored upper airway breathing/shortness of breath with minimal tracheal wheezing, tightness, and mild dry cough (beginning of illness and recently recurring (3 wks)), Raised BP and HR (HR has gone up to over 120 resting and BP has gone over 150 resting- normal 102-108 BP, HR has been around 100), Night Sweats, Dry Flushing (Face, Chest, Upper Arms, Upper Legs), Bloody nose, Significant joint and random sharp muscle pain, Abdominal dissension, Skin itching and pigmentation changes, and Swollen lymph nodes (one to size of egg and has decreased). I have Celiac Disease, Asthma, Allergies, Hypothyroidism, Endometriosis, and Mild Rheumatoid Arthritis. I follow a plant-based diet and am strictly gluten free. It took most of my life before the Celiac was diagnosed because I was somehow gaining weight despite diet, exercise, and active lifestyle (when well) and consistently showing healthy pathology- during the Endoscopy, my villi were completely eroded and my biopsies were highly positive- I'm difficult to diagnose because my body works this way- complicated.

After the CT neck results, should I still push for biopsies of the swollen and firm, but 1cm and less, lymph nodes, just in case? Is it possible for the sphenoid sinusitis to cause a pituitary disorder that may be causing the abnormal hormone levels and problems? Is it possible to have carcinoid syndrome or some other type of cancer that is not showing up clearly? Can my diet be fighting whatever is happening to me and keeping these results from strongly showing up? I'm hoping someone else may notice something or anything at all as I am getting desperate and beyond ready to get well and back to my life.

Thank you!
doctor
Answered by Dr. T Chandrakant (1 hour later)
Brief Answer:
Investigation as advised.

Detailed Answer:
Hi.

Thanks for an elucidate history and mentioning the reports in detail.

To recollect few important points: Corrected Thyroid problem, laryngoceles, multiple enlarged lymph nodes, cobblestoning; recollected the whole history you have mentioned...

Yes, initially multiple FNAC= (Fine needle aspiration cytology) from the most suspected lymph nodes, preferably under ultrasonography guidance can help to get a diagnosis. If the FNACs are suggestive of something , it is better to push for an excision biopsy of the suspected lymph node/s can really help to get some diagnosis.

The Pituitary is not involved unless there is a highly inflammatory process going on in the sphenoid sinus. If this is so , your case is going to be a rare and notifiable case. To confirm you can request for the Dynamic contrast pituitary MRI scan.. This is really going to be a good idea...

As the terminal ( last part of the small intestine) has the same lymphoid tissue collection in the form of patches, I do expect them to be involved as all other sites of lymph nodes are showing enlarged lymph nodes.
And this can be very well be the reason for your reflex-vomiting for the last 3 months...

Capsule endoscopy ( to be repeated if done once) may give an idea.. about the possibility of this and the carcinoid or so. Even a Diagnostic Laparoscopy can sometimes help.

Carcinoids are always diagnosed by high degree of suspicion, and you are great in having this.
The tests for the carcinoids must have been run through I suppose.

Diet as you think may not really be associated with not showing or otherwise. It can have an allergic manifestations at the moment.

There are so many forms of an ''autoimmune diseases'', out of the reach of diagnosis and treatment too. This should also be kept in mind.

I hope you have already tried alternative therapy like Yoga, Acupressure or puncture. This really helps in many patients who could not be diagnosed. The major issue is getting a healthy life.

Please go ahead as planned and it is but possible to get a diagnosis. Once the diagnosis is got , treatment is always easy and effective.

Above answer was peer-reviewed by : Dr. Raju A.T
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Dr. T Chandrakant

General Surgeon

Practicing since :1984

Answered : 18947 Questions

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Should biopsy be done for swollen lymph nodes?

Brief Answer: Investigation as advised. Detailed Answer: Hi. Thanks for an elucidate history and mentioning the reports in detail. To recollect few important points: Corrected Thyroid problem, laryngoceles, multiple enlarged lymph nodes, cobblestoning; recollected the whole history you have mentioned... Yes, initially multiple FNAC= (Fine needle aspiration cytology) from the most suspected lymph nodes, preferably under ultrasonography guidance can help to get a diagnosis. If the FNACs are suggestive of something , it is better to push for an excision biopsy of the suspected lymph node/s can really help to get some diagnosis. The Pituitary is not involved unless there is a highly inflammatory process going on in the sphenoid sinus. If this is so , your case is going to be a rare and notifiable case. To confirm you can request for the Dynamic contrast pituitary MRI scan.. This is really going to be a good idea... As the terminal ( last part of the small intestine) has the same lymphoid tissue collection in the form of patches, I do expect them to be involved as all other sites of lymph nodes are showing enlarged lymph nodes. And this can be very well be the reason for your reflex-vomiting for the last 3 months... Capsule endoscopy ( to be repeated if done once) may give an idea.. about the possibility of this and the carcinoid or so. Even a Diagnostic Laparoscopy can sometimes help. Carcinoids are always diagnosed by high degree of suspicion, and you are great in having this. The tests for the carcinoids must have been run through I suppose. Diet as you think may not really be associated with not showing or otherwise. It can have an allergic manifestations at the moment. There are so many forms of an ''autoimmune diseases'', out of the reach of diagnosis and treatment too. This should also be kept in mind. I hope you have already tried alternative therapy like Yoga, Acupressure or puncture. This really helps in many patients who could not be diagnosed. The major issue is getting a healthy life. Please go ahead as planned and it is but possible to get a diagnosis. Once the diagnosis is got , treatment is always easy and effective.