CWH C1389148

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From the note:

• 11-year-old boy

• Bilateral cervical + left supraclavicular lymphadenopathy since May

• Persistent fever

• Neutropenia (WCC 2.9, neutrophils 1.7 initially, history of neutropenia)

• ESR elevated, LDH 542

• Neck USS: reactive nodes, no abscess

• Blood/urine cultures negative

• Viral/infectious work-up (CMV, EBV, HIV, toxoplasma, Bartonella) being sent

• TB testing (QuantiFERON) planned

• ENT considering biopsy if infectious work-up negative

Top 3 differential diagnoses

1. Lymphoma (Hodgkin > Non-Hodgkin)

   • Supraclavicular node is concerning

   • Persistent lymphadenopathy (>6 weeks)

   • Fever (B symptoms)

   • Elevated LDH

   • Neutropenia may reflect marrow involvement or inflammatory process

2. Infectious cause

   • EBV/CMV infectious mononucleosis

   • Bartonella, toxoplasmosis

   • Tuberculous lymphadenitis (despite no TB contacts)

   • Less likely acute bacterial lymphadenitis given bilateral nodes, chronic course, negative cultures, no abscess

3. Leukaemia (ALL/AML)

   • Fever + lymphadenopathy + neutropenia

   • Elevated LDH

   • Can present without obvious blasts initially

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Top 3 investigations

1. Excisional lymph node biopsy (preferred over FNA)

   • Highest-yield investigation

   • Histology

   • Flow cytometry

   • Microbiology (including TB culture/PCR if indicated)

2. Peripheral blood film ± bone marrow aspirate/trephine

   • Look for blasts or marrow infiltration

   • Essential if cytopenias persist or blood film is abnormal

3. Contrast CT neck/chest/abdomen/pelvis (or PET-CT if lymphoma confirmed)

   • Assess extent of lymphadenopathy

   • Evaluate mediastinal disease and staging

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Additional important tests

• EBV/CMV serology

• HIV

• Bartonella and toxoplasma serology

• QuantiFERON/TB testing

• Repeat FBC with differential

• CRP/ESR

• Uric acid and repeat LDH

• Ferritin

• Blood cultures (already done)

Most likely diagnosis

Given the persistent bilateral cervical plus supraclavicular lymphadenopathy, fever, elevated LDH, and neutropenia, lymphoma should be excluded urgently, even though infectious causes remain possible. An excisional lymph node biopsy is the key next diagnostic step if the infectious evaluation is unrevealing or the nodes persist.