A 22-year-old woman presents with painless cervical lymphadenopathy, night sweats, and generalized pruritus. An enlarged cervical lymph node is removed for diagnosis. On cut surface, it shows broads bands of fibrosis. Histologically, the affected lymph node contains a mixture of cells, including lymphocytes, histiocytes, eosinophils, plasma cells, and scattered large cells with prominent nucleoli. Which of the following is the most likely condition?
The history is consistent with Hodgkin disease (HD). Impoant clinical clues include painless lymphadenopathy, night sweats, and generalized pruritus. All forms of lymphoma lead to effacement of the nodal architecture on cut surfaces. In this case, fibrotic bands appear to divide the node into multiple nodules. This finding is suggestive of the nodular sclerosis subtype of HD, which usually affects children and young adults. Fuhermore, the histologic finding of large cells with prominent nucleoli (Reed-Sternberg cells) within a polymorphic cellular background is consistent with HD. Remember that the nodular sclerosis type of HD is characterized by a subtype of Reed-Sternberg cells called lacunar cells. These are similar to classic Reed-Sternberg cells in their large, inclusion-like nucleoli, but appear surrounded by a clear halo (hence the attribute "lacunar"). Cat-scratch disease is due to a small gram-negative bacillus (Baonella henselae), which is transmitted to humans by a scratch or a bite by a cat. Swelling of lymph nodes develops days after the skin lesion. The history is generally sufficient for diagnosis, but occasionally a lymph node biopsy is performed for confirmation. This reveals characteristic stellate abscesses, which are also seen with tularemia and lymphogranuloma venereum. Reactive non-specific lymphadenitis results in hyperplasia of germinal centers of lymphoid follicles, where maturation of B-cells takes place--follicular hyperplasia. This is probably the most common form of lymphadenopathy in otherwise healthy individuals. However, a careful search of the inciting conditions (dental abscess, skin infection, etc.) must be undeaken before reaching a conclusion of reactive lymphadenitis without histologic analysis. Non-Hodgkin lymphoma is associated with effacement of lymph node architecture, and replacement by a population of atypical or frankly anaplastic lymphocytes. The presence of a polymorphic cellular background, and especially the finding of Reed-Sternberg cells, excludes non-Hodgkin lymphomas.
Cat-scratch disease
Hodgkin disease
Reactive non-specific lymphadenitis
Non-Hodgkin lymphoma