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Enlarged lymph nodes in the neck and fever

Background: 25 year old woman who’s generally healthy. Average height and weight.

About two and a half weeks ago, I began having pain and tenderness in the left side of my neck, specifically near the lymph node right under my jaw bone. No other symptoms were present at this time aside from and overall fatigued feeling and headache.

The pain and tenderness didn’t subside and 5 days later, it began on the right side of my neck. However, this time, I felt a large, hard lump to the right of my Adam’s apple. This was tender and painful and immovable when pressed. At this time I still had no upper respitory or other symptoms other than a headache so I went to my GP on Monday, March 26th. She found several prominent swollen nodes in my neck and ran a full blood count along with tests for lupus and thyroid diseases, including hoshimotos (given familial history). She also referred me to get an ultrasound on my neck as soon as possible to see if the nodes themselves were enlarged or there was a mass.

The night after I went to the GP I began running a fever of 101 with chills and lower back pain. I called the next morning to tell her about the extreme back pain and she prescribed me medication to treat a possible kidney infection or sepsis, as I had thought I may have had a UTI a couple weeks back but symptoms had passed after one day. Prescribed a three day, twice a day strong antibiotic (started w a c, can’t remember the name).

My fever continues and I go to the ultrasound on Wednesday, March 28th, where they find some of my lymph nodes are rounded and several enlarged. One is 1.5 cm (normal lymph nodes should not exceed 10 mm). I still have a persistent low grade fever (all hours of the day, but relieved with anti fever medication, aspirin). Results of the ultrasound recommend I should get a CT scan as soon as possible. By this time my blood work returns as well. No mono, no lupus, no flu, no connective tissue disorders, no thyroid issues. All it shows is an elevated “new white blood cell” count and sedementation rate was elevated. Everything else normal. By this time I’m beginning to experience loss of appetite as well. This will continue.

Friday, March 30th I receive a CT scan with contrast. My low grade fever still persists. This Saturday the right start of my throat starts to hurt as well. Almost like a razor blade.

Monday, April 2nd, I receive some unsettling results from my CT scan. “Prominent enhancing lymph nodes with mild surrounding inflammatory change and heterogenous appearance. The largest node on the right, at level 2a is 19x9x26 mm. And additional node on the right is 13x9x22mm. On the left, on node 2a is 21x9x26 mm. One more significant on the left 2b is 15x10x23.

Other than the lymph nodes, all other aspects of the UR are unremarkable. Conclusion: nonspecific bilateral adenopathy with surrounding inflammatory changes. Infectious and inflammatory causes such as Kikuchi and castlemans disease are considered. Neoplasm such as lymphoma is also in the differential. Reccomend tissue sampling.  

I have a fine needle biopsy scheduled for next Monday (had to wait bc I’ve been taking antiinflamatory medication). As a side note, my dr told me she’s worried on the phone. What dr says they’re worried?! She reccomended biopsy as soon as possible. But I’m at a loss! I still have a low grade fever, chills, loss of appetite and the sore throat has nearly subsided. Sometimes periods of hot flashes (maybe as my fever breaks). Anyone have similar symptoms? I can’t help but panic thinking it’s lymphoma, as my grandma has non-hodgkins lymphoma. Any suggestions are greatly appreciated. Please help.
3 Responses
1081992 tn?1389903637
Hi, offhand it seems less like cancer and more like reactive nodes. Maybe you have an unusual infection. Or else you might have exaggerated immune reactions -- do you have a family history of odd immune conditions besides the Hashimoto's Disease? Did you happen to have really bad mono as a teenager?

Did your ultrasound .say that the 'fatty hilum' was not present? That would be concerning but it does not automatically mean cancer.

The nodes are not that super large nor that rounded. If they came up suddenly then stopped growing, that tends against cancer and towards immune reaction. There is not really an absolute upper limit of size that is definitive of cancer.

I think if your doc was really, really worried she would have ordered an excisional (surgical) biopsy of a whole node. That would be almost always definitive for cancer, but carries more risk than a needle. The needle though, has the possibility of a false negative - if it just happens to miss the right spot(s).

However, the needle biopsy might be looking for certain cells that you'd expect to find in the mystery condition called Kikuchi disease. If so, then you'd just wait it out until everything subsides. Your age and gender fits, also it being confined to the neck.

The other mystery condition, Castleman's, might fit somewhat.

I don't know why the path report doesn't suggest TB for the DDx.

Btw, I wouldn't personally take anything to reduce fever unless it is very very high -- because the fever is part of the body's defense against infections.

Also, btw, lymphoma is usually not painful, except for certain conditions such as the center-node cells dying (necrosis) and the center then filling with blood which causes pressure and pain. But that probably would have shown on the scans.

Let me know how it turns out. Good luck with the biopsy. I wouldn't go in thinking the worst because the worst doesn't quite fit.
Thank you so much for your reply. I have no bigotry of mono as a teenager and tested negative on the blood test. I’m wondering if more blood testing needs to be done...

The exact blood tests that were done were: CBC, T4 free, TSH, Ana w/ reflex, sedimentation rate, thyroid peroxidas e, Epstein-Barr virus VCA, IgM, CBC auto differential. All were negative aside from high “new white blood cell” count and sedimentation rate indicates infection.

I’m really worried because I just read the exact report from the ultrasound and it indicates the largest node is heterogenous in appearance and hypoechoic. Color flow is seen within the periphery of this node and within a possible minimum echogenic hilum.

There is a rounded .5x.5x.5 right level 2 lymph node without echogenic hilum along the inferior aspect of the larger palpable node. Thyroid appears normal. Recommend ultrasound guided biopsy.

I have also noticed another large lymph node on the right under my jawline. I’m unsure if this one was indicated but it has gotten larger in that I can feel it now where as a few days ago I couldn’t.

I also don’t know if it’s related but I’ve been having pain on the outside of my right foot every morning that makes it difficult to walk without a limp. It’s like a stabbing pain that almost feels like a cramp.

It usually gets better by the afternoon but this morning it appears red and warm and swollen. No injury occurred to my foot though.

My fever persists. This is day 10 with fever.

Could this rounded lymph node be explained by something else like infection or should I be concerned for cancer?

Any feedback is greatly appreciated thank you so much.
1081992 tn?1389903637
Well, we know that you don't have just ordinary reactive nodes.

Still, I don't think that there's anything in your scans that can't be accounted for by raging inflammation. Even the hilum can be effaced by inflammation without any cancer present.

Blood flow showing on a Doppler sono can be from angiogenesis from cancer, but alternately from inflammation. That happens.

To my mind, the foot is important because it seems to be due to generalized immune activation and that is not cancer. That kind of inflammation is usually worse in the morning. Do you sleep on your side so that the painful part is pressed against the mattress?

Most people with lymphoma have no symptoms at first. They just by chance discover a painless bump, e.g. when showering.

Fever typically comes later in lymphoma but early in immune activation.

Was the round .5cm node confirmed by the CT?  If not, then maybe that was inaccurate. I'm guessing it's more deep than superficial, and that's why it's a guided rather than unguided needle that's recommended. Sono isn't so good the deeper you go.

I've seen cases where a sono gets repeated and the 2nd one doesn't show what the 1st one did. Sometimes the operator is better or worse.

A node being homogenous (not heterogenous as is yours) is possibly the worst since every normal cell had been replaced by cancer dells, each identical to the other.

What were your lymphocytes and neutrophils, plus the ranges?

Do you react terribly to bee stings?

"Color flow is seen within the periphery of this node" That'd be from the surrounding inflammation. The worst would probably be one large interior vessel, which you don't seem to have.
Hi, thanks for the quick response. So I went to the dr. Yesterday for my foot because he pain became unbearable in the morning and it appeared red and swollen as well as slightly warm to the touch. I still had a low grade fever yesterday morning (99.3, this is day 11). The dr. Stated she thinks it was because of an infection (I had an old cat scratch above, I mean pretty old at least two weeks) and she prescribed me amoxicillin pot-clavulante 875 mg twice a day and a Medrol dose pack of steroids. Also tramodol 50 mg for the pain as needed. I started the antibiotic and steroid yesterday and woke up this morning with basically no pain in my foot. Still appears slightly reddish purple but not nearly the same mount of swelling. She also recommended an X-ray because of the pain, (to see if infection had spread to the bone) however since I was no longer having pain today, I called to see if I still needed X-ray and she said no. Also this morning my fever has broke. I’m now 97.3.

Could this infection have been related to the swollen neck lymph nodes? Seems odd it would be nodes so far from the site but I’m not sure. My lymph node, particularly the one under my right jaw is still enlarged but it hasn’t been tender.

Blood test results from earlier are as follows:
ANC- 8,055 (range 1,500-7,800 cells/uL)
ALC- 1,514 (range 850-3,900 cells/ uL
Monocytes absolute- 618 (range 200-950)
Neutrophils relative- 78.2 (no range indicated)
Lymphocytes absolute- 14.7 (no range)
Sed rate by modified westergren- 53 (range < or = to 20)

Getting the biopsy on Monday. Curious as to what you think in regard to the foot infection.
1081992 tn?1389903637
Hi, I just have a few minutes for now but I want to say this: hearing "cat scratch" changes everything. Cat Scratch Fever is known for causing swollen nodes remote from the site of the scratch. It's true as you say that it's very far from the leg to the neck - but I bet it's not the first time that it's happened to somebody that way.

Your rebound from the antibiotics is also remarkable. I would want to see what happens further before having a biopsy.

Can you get in touch with your doc and see about postponing the biopsy while you observe what happens and think about canceling it completely?

That's what I'd want to do. I think you have a special sensitivity to the Bartonella bacteria and your immune system went into hyper drive over it.

If your biopsy is merely to check for cancer then it is an entire waste. But of they also will check for the granulomas and the immune cells characteristic of Bartonella, then it's not quite a total waste but perhaps it's still unnecessary - if all gets better anyway. Thank goodness it's not a surgical biopsy.

Please let me know, when you read this. I feel that it's important for you not to just go along like a cog in a machine :)
I know somebody who gets a terrible skin reaction just from being licked by a cat. The immune system can do mysterious things.
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