WBR0005

Author	PageAuthor::Anonymous (Edited by Will Gibson and Alison Leibowitz)
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Internal medicine
Sub Category	SubCategory::Oncology, SubCategory::Oncology
Prompt	[[Prompt::A 52-year-old man presents to his primary care physician for recent fatigue, low-grade fever, anorexia, and pruritus. He states that he can feel small bumps under the skin in his neck and that they seem to become painful when he drinks alcohol. Laboratory studies reveal the following: WBC - 6,500/mm 3 Hematocrit - 45% Hemoglobin - 15 g/dL Creatinine - 0.8 mg/dL Glucose - 85 mg/dL You refer him to a surgeon to obtain a lymph node biopsy. The histology of the biopsy taken is shown below: What is the most likely diagnosis?]]
Answer A	AnswerA::Tuberculosis
Answer A Explanation	[[AnswerAExp::Tuberculosis is a common infectious disease, especially in the developing countries, caused by mycobacteria, mainly Mycobacterium tuberculosis. Tuberculosis most commonly attacks the lungs (as pulmonary TB) but can also affect the central nervous system, the lymphatic system, the circulatory system, the genitourinary system, bones, joints and even the skin. The presence of acid-fast-bacilli (AFB) on a sputum smear or other specimen often indicates TB disease (at least 10,000c is needed on the smear to get a postive acid fast bacilli (AFB) stain).]]
Answer B	AnswerB::Hepatitis
Answer B Explanation	[[AnswerBExp::Although this is highly unlikely. Hepatitis refers to liver injury characterized by presence of inflammatory cells in the liver tissue. The symptoms include: Abdominal pain or distention, breast development in males, dark urine and pale or clay-colored stools, fatigue, fever, itching, jaundice (yellowing of the skin or eyes), loss of appetite, nausea, vomiting, and weight loss. Hepatitis typically causes a rise in liver function tests. In particular, there is often a disproportionate rise in transaminases relative to the alkaline phosphatase, but this is not universal and the pattern can be suggestive of cause. Hepatitis is usually diagnosed by serological tests, depending on the cause.]]
Answer C	AnswerC::Metastatic cancer
Answer C Explanation	AnswerCExp::This is unlikely due to the absence of classic symptoms of malignancy in this patient such as weight loss and derangement of laboratory parameters.
Answer D	AnswerD::Non Hodgkin's lymphoma
Answer D Explanation	AnswerDExp::The presence of Reed-Sternberg cells differentiates Hodgkin's from a non-hodgkin's lymphoma.
Answer E	AnswerE::Hodgkin's lymphoma
Answer E Explanation	AnswerEExp::The histology above demonstrates the presence of Reed-Sternberg cells which is pathognomonic to Hodgkin's lymphoma.
Right Answer	RightAnswer::E
Explanation	[[Explanation::This patient has many classic signs of lymphoma which are: low-grade fever, night sweats, weight loss, itchy skin (pruritus), or fatigue. Classically, involved nodes are painful after alcohol consumption, though this phenomenon is rare. Patients may also present with a cyclic high-grade fever known as Pel-Ebstein fever. Systemic symptoms such as fever and weight loss are known as B symptoms. The laboratory results are indicative of an early disease. The biopsy picture shown above reveals the presence of complete or partial effacement of the lymph node architecture by scattered large malignant cells known as Reed-Sternberg cells (typical and variants) admixed within a reactive cell infiltrate composed of variable proportions of lymphocytes, histiocytes, eosinophils, and plasma cells. The Reed-Sternberg cells are identified as large often bi-nucleated cells with prominent nucleoli and an unusual CD45-, CD30+, CD15+/- immunophenotype. In approximately 50% of cases, the Reed-Sternberg cells are infected by the Epstein-Barr virus. Around one to five percent of patients with Hodgkin's disease experience alcohol-related pain; it is a rare but highly specific presentation for Hodgkin's lymphoma. Educational Objective: A middle-aged/elderly patient with lymphadenopathy and classic B symptoms has a high probability of having lymphoma. The presence of Reed-Sternberg cells on histology confirms the diagnosis of Hodgkin's lymphoma. References: First Aid 2012, page 389 Bobrove AM (June 1983). "Alcohol-related pain and Hodgkin's disease". The Western Journal of Medicine 138 (6): 874–5. http://www.wikidoc.org/index.php/Hodgkin%27s_lymphoma]]
Approved	Approved::No
Keyword	WBRKeyword::Cancer, WBRKeyword::Hodgkins, WBRKeyword::Lymphoma, WBRKeyword::Leukemia, WBRKeyword::Histology
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