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Dr. Andrew Rynne

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What might be causing the fluctuation in lymph node?

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Dr. Karen Steinberg

Internal Medicine Specialist

Practicing since :1981

Answered : 824 Questions

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Posted on Mon, 18 Aug 2014 in Lump
Question: My left supraclavicular lymph node has been fluctuating in size for 8 months. During a XXXXXXX ultrasound, the node was 18mm at longest dimension & described as "round solid mass with distal acoustical shadowing." During a XXXXXXX CT scan, the node was under 1cm and a right submandibular node was 14mm. I’ve reported come-and-go drenching night sweats & severe fatigue for the last 15 months at least. My Epstein Barr tests all came back high last month (Nuclear Ab.IgG, Capsid Ab.IgM, & Capsid Ab.IgG). My CBCs are always normal. My surgeon hesitates to perform biopsy because of the fluctuations in size. All things considered, my doctors are unsure of my diagnosis. Infectious mononucleosis and lymphoma are “high on the differential” though neither seems to fit perfectly. My cousin was just diagnosed with Hodgkin's lymphoma and another cousin on the same side of my family is being investigated for lymphoma as well. Is it possible for HL to run in families? My doctors say that lymph nodes don't fluctuate in lymphoma and mono doesn't last this long. What other conditions could this be?
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Answered by Dr. Karen Steinberg 40 minutes later
Brief Answer:
Lymphoma may run in families

Detailed Answer:
Hi, thank you for using Healthcare Magic. Yes, familial cases of both Hodgkin and non-Hodgkin lymphoma have been reported in families. It is true that lymph nodes don't tend to fluctuate in size in lymphoma, and mono doesn't usually last so long. However, Epstein Barr virus is associated with lymphoma, and risk is increased if you've had that virus.

Other infectious processes can cause problems with lymph nodes. I am concerned about the drenching night sweats and severe fatigue. Such symptoms can be associated with either a chronic infectious process or lymphoma. Tuberculosis could be present in lymph nodes and causing a problem, as well as other unusual infections. The only way sometimes to diagnose these is to do a biopsy and culture the lymph node tissue.

I understand your doctors' hesitance to proceed with a biopsy because of the fluctuating size and atypical presentation. However, I think at this point it is necessary. The biopsy can be done not only to look for lymphoma, but also for tuberculosis and other unusual infections. The only way left to know what is causing the fluctuating lymph nodes and your other symptoms is to look at the gland itself.

Hope this answers your query. If you have further questions, I would be happy to answer them. Wishing you a speedy recovery.
Above answer was peer-reviewed by : Dr. Raju A.T
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Follow up: Dr. Karen Steinberg 19 hours later
Hello again. Thanks for your answer! Here’s my follow-up:
I saw the immunologist this morning and it was a great comfort to me that--without showing him your response--he reiterated your answer. He had his nurse give me the tuberculosis test shot and a pneumo vaccine to see if my immune system responds healthily. I have to go back in two days for the TB test screening and in four to six weeks for the pneumo vaccine response. He also ordered the following tests from the lab: "HIV, Tetanus, Dip Tox, T & B Lymph, Comp Tot, MM Panel." He said that if he found something suspicious among the results, I would be referred to an infectious disease specialist. If not, he would refer me back to the hem-onc because if this isn’t an infection, it must be lymphoma. Do you agree? The immunologist also felt that biopsy is the next step, though he talked about fine needle aspiration, not excisional biopsy as recommended in cases of lymphoma. My final questions for you (that he did not have time to answer) are:
(1) What specific infections are on the table?
(2) Are high EBV antibodies associated with tuberculosis?
(3) Is EBV associated with infections other than mononucleosis? What are they?
doctor
Answered by Dr. Karen Steinberg 48 minutes later
Brief Answer:
Tuberculosis would be highest on the list

Detailed Answer:
Hi, I am glad to hear things are moving forward for you. Tuberculosis would be my first thought. There are related bacteria called mycobacteria that could also be causing it. Brucellosis is another. Certain fungal infections such as histoplasmosis and HIV are other potential causes.

I am not aware of any direct association between EBV antibodies and TB. What I would say is the high antibodies may indicate some suppression of your immune system which could make you more susceptible to TB and the other infections I've mentioned.

EBV has been associated with a condition called Chronic Fatigue Syndrome, but there is no definite proof that it's a cause. EBV is also associated with increased risk for lymphoma.

As your other doctors have said, the differential is between lymphoma and an infectious disease. With significant TB, response to the skin test might be decreased due to suppressed immunity, so a negative test could be a false negative. Also if it's another type of mycobacterium, the test does not usually turn positive.

I can't say for certain that the tests the immunologist is doing can rule out an infectious disease entirely. Examination and culture of the lymph node tissue would be the most definitive test in my humble opinion.

If your doctors don't want to do an excisional biopsy at this time, perhaps they would be agreeable to a fine needle aspiration. Enough information may be obtainable from that to point you to a more specific diagnosis.

Hope this is helpful.


Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
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Follow up: Dr. Karen Steinberg 3 days later
Hello again and thanks. You’ve helped me so much! This is my final follow-up.

My tuberculosis skin test came back negative with a 0 mm response. The nurse reading the result told me that TB has been ruled out, regardless of immune dysregulation. I will wait to hear what the immunologist says about that at my follow-up visit as you have indicated that false negatives may occur.

Since my last answer from you, I saw the oncologist who said that my PET-CT was completely clear and that I could not have lymphoma or active TB, otherwise the PET scan would have indicated something. He says I have mono, regardless of how long it has lasted. I have a hard time accepting that since my white blood cell count has been normal throughout, I have no sore throat, and my lymph nodes are not at all tender. The oncologist did concede that it could be TB, but insisted that an active TB infection would have shown itself on the PET scan. Can "inactive" TB cause night sweats, fatigue, and lymphadenopathy?

Don’t get me wrong, I am thrilled that it is not cancer! I am just perplexed at the inconsistencies in my imaging tests, taken within one-and-a-half months of each other. My ultrasound showed a 18 mm left supraclavicular lymph node; the subsequent CT showed the same node at only 9mm and two submandibular nodes over 1 cm plus an “umbilical hernia;” and the PET-CT showed none of these things, just “lesions” in the parotid gland that don’t meet size criteria. The oncologist says that the PET scan is the most highly specific of these imaging tests, and that I can disregard the earlier scan reports. This frustrates me as the earlier scans, particularly the US, correlate better with the palpable, fluctuating abnormality that I experience in my left neck/shoulder area.

This morning a whole new lymph node has swollen up in the front of my neck, making it uncomfortable to swallow. My symptoms have been going on for more than a year (night-sweats, fatigue, and malaise), but the lymph nodes have only been fluctuating for eight months. I’ve lost 25 pounds in three months of dieting, and would expect to have more, not less, energy with such a weight loss. Could mono really explain this?

I have recently developed other symptoms, too, though I did not mention them to you earlier since they may not relate to the problem we are discussing. I will throw them in now as a last ditch effort that something might leap out at you, perhaps a specific infection or other condition for which to request screening. I tend not to share this additional list of symptoms with my doctors for fear of sounding like a hypochondriac. Perhaps these relate to my polycystic ovary syndrome and associated insulin resistance, already diagnosed.

The symptoms are:
1. Daily numbness and tingling in the feet and legs (for 2 years; possibly related to pre-diabetes per neurologist)
2. Painful, new carpal tunnel in both wrists (for 6 months; just diagnosed in XXXXXXX per EMG/NCV by neurologist)
3. Tender, scaly skin behind left ear (appeared just after left supraclavicular lymph node started fluctuating; possibly incidental)
4. Rectal bleeding during my last three periods (confirmed by scope at the ER, though the source was not determined; possibly endometriosis per ER physician)

Are there any diagnoses that might explain this constellation of symptoms in conjunction with fluctuating lymph nodes, fatigue, and night sweats? Particularly, I am concerned with the carpal tunnel, as my neurologist finds it strange that I have nerve damage in both wrists equally. What lab tests, other than those already ordered, should I request from my doctors? If all of the tests ordered so far come back normal, is there any other direction my doctors could take my testing?

Thanks for sharing your expertise! You’ve already earned a great review from me.
doctor
Answered by Dr. Karen Steinberg 37 minutes later
Brief Answer:
TB has not been ruled out

Detailed Answer:
Hi. I am glad lymphoma has been ruled out. A negative TB test does not completely rule out TB. With widespread TB, the test can be falsely negative. Also, other mycobacteria similar to TB can cause your symptoms, and the TB test will be negative for them.

Inactive TB does not cause nightsweats, fatigue, and lymphadenopathy. It can only be picked up on a skin test or sometimes a chest x-ray (signs of previous infection).

I can't explain your constellation of symptoms easily with one diagnosis. It could be a couple of things going on. Certainly the numbness and tingling could be related to pre-diabetes. Carpal tunnel could be related to a variety of conditions that might cause pressure on the median nerve. Thyroid disease and infiltrative conditions can do this. I'm sure you've already been tested for thyroid. Now we are looking for unusual conditions such as sarcoidosis. I would also check for syphilis, as advanced syphilis can cause all sorts of unusual symptoms (including neurological) and is easily diagnosed with blood tests.

Ultimately, I think a lymph node biopsy or aspiration should be done. As I mentioned, there are unusual infections that may only be diagnosed by culturing the lymph node tissue in special media. The cells can also be examined for infiltrative conditions. Since your presenting complaint was the fluctuating lymph nodes, that is what needs to be looked at. Hope this helps.
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
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