Multiple Supraclavicular Nodes

The Case:  A 45-year-old Asian man presents with a 3-week history of weight loss, poor appetite, fatigue, intermittent sweats, and a nonproductive cough. The patient, a recent immigrant, denies previous illness; he uses alcohol occasionally. He is cachectic but is in no acute distress. Vital signs are normal. No heart murmurs are audible; rales are noted in the upper lung fields. The abdomen is normal. Palpation of the neck reveals multiple firm, nontender supraclavicular nodes. Results of a posteroanterior and lateral chest radiograph are normal. Which of the conditions in the differential do you suspect? • Coccidioidomycosis • Gastric carcinoma • Histoplasmosis • Infectious mononucleosis • Tuberculosis Discussion on next page , Discussion:  Lymphadenopathy in adults may result from an increase in macrophages and normal lymphocytes in response to an antigen (viral or bacterial illness); an infection in the nodes themselves (lymphadenitis); or proliferation of macrophages or neoplastic lymphocytes (lymphoma). Adenopathy may be either localized or regional. Generalized adenopathy may be associated with systemic viral infections (infectious mononucleosis, varicella, and adenovirus or HIV infection); bacterial infections (tuberculosis and typhoid); drug reactions; and lymphomas. Localized adenitis is most often attributable to infection with staphylococci or beta-hemolytic streptococci. Supraclavicular nodes drain the lungs, abdomen, thorax, head, neck, and mediastinum. In the absence of other adenopathy, supraclavicular nodes of any size or consistency in this region strongly suggest malignancy, especially of mediastinal or gastric origin. Futher investigation revealed agastric carcinoma in this patient. Coccidioidomycosis, histoplasmosis, and tuberculosis may all present with supraclavicular adenopathy. Given this patient’s symptoms and immigration history, tuberculin skin testing is warranted, although the negative chest radiograph makes tuberculosis fairly unlikely. Histoplasmosis is caused by a dimorphic fungus found in temperate climates throughout the world. The disease is endemic to the Missouri, Ohio, and Mississippi river valleys. Areas inhabited by birds and bats usually contain highly infectious soil. Most infected patients are asymptomatic, but some report malaise, fever, cough, abdominal discomfort, chills, and dyspnea. The disease may occur in persons of all ages but preferentially affects those with immature or compromised immune defenses. In acute histoplasmosis, the chest radiograph is usually normal, although hilar and mediastinal nodes may be present. Further laboratory studies, including blood and sputum cultures and complement-fixing and immunoprecipitating antibody assays, are warranted. Coccidioidomycosis, also known as valley fever, results from a fungal infection and is usually seen in patients with compromised immune systems. It is the second most common fungal infection encountered in the United States. Suspect the disease in anyone who lives in or has traveled through an infected area, such as the southwestern United States or northern Mexico. Coccidioidomycosis may manifest as either a mild pulmonary infection or a severe systemic disease. Symptoms, which resemble those of influenza, include chills, chest discomfort, and fever. Chest radiographs are often normal in patients with milder forms of the disease but in severe cases may reveal multiple parenchymal nodules or lung abscesses. The diagnosis is confirmed by positive results on sputum cultures and coccidioidomycosis complement-fixation titer.  Infectious mononucleosis, although associated with generalized symmetric adenopathy, usually does not involve the supraclavicular nodes. FOR MORE INFORMATION: Goldman M, Johnson PC, Sarosi GA. Fungal pneumonias: the endemic mycoses. Clin Chest Med. 1999;20:507-519. Miller DR. Hematologic malignancies: leukemia and lymphoma. In: Miller DR, Baehner RL, eds. Blood Diseases of Infancy and Childhood. St Louis: Mosby Inc; 1995:745-749.