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May 22, 2005
Lump in the armpit
A patient presented on friday afternoon at 4:00pm to have his knee checked because it had been bothering him now that he was exercising regularly.  And, oh, "could you also take a look at this lump that I noticed in my ampit?"

(The knee story is that he's had a bad knee for a while and didn't want a replacement but now he might have to get one....on to the armpit)

So I ask him to show me this lump.  He raises his arms and points to the mass under his left arm.  Quick version of HPI: he noticed it a week or so ago, tender to the touch, no fever, chills, nightsweats, or weight loss recently.  He denies fatigue, muscle aches, cough, sore throat, runny/stuffy nose, basically denies everything, he has been in great health.  He has not noticed any other lumps on his body.  He has been exercising regularly and eating well (did i mention he had been housesitting in Bermuda for the past 2 months!! um, can i have that job?)

PE: The mass is firm, mobile, mild discomfort to the touch, no warmth, no erythema, no discoloration of the overlying skin. No other palpable nodes in the vicinity or elsewhere on the body. 

Preceptor takes a look...it's now 4:30pm, and wants him to schedule with a surgeon immediately for a biopsy.  Although he doesn't tell the patient, the Dr. believes, even without the classic sx, the diagnosis is Hodgkin's.  Seeing how it's friday at 4:30, this will all have to wait until Monday.  Not the best way to start the weekend.

Hodgkin's Lymphoma:
Def'n-  malignant disorder of lymphoreticular origin; characterized by the presence of Reed-Sternberg cells (multinucleated giant cells).
Age of onset: bimodal distribution 15-34 yo and over 50yo.
Signs and SX: pts present with fever, night sweats, weight loss, malaise, dry cough, pruritis, and increased pain at tumor site after EtOH consumption.
Treatment: main modalities are chemo and radiation but these vary depending on the stage. (argh!!!! this geriatric computer won't let me link so for your reading pleasure I will summarize the staging...)
Stage 1- only found in 1 node or lymphoid structure
Stage 2- involves 2 or more nodes in the same region on the same side of the diaphragm.
Stage 3- involves nodes on both sides of the diaphragm.
Stage 4- disseminated disease.

How to stage:
Biopsy
Imaging studies (CT, xray, Gallium scan)
Hematologic studies (CBC, ESR, BM biopsy)
Biochemical studies (LFTs, renal fxn, LDH, alb, Ca2+)

In this man's case, we only found the one axillary mass on PE and no constitutional symptoms but we will await the biopsy result.
Posted At : 9:55 PM. | Link | Rotation 5 04-05 | Comments (6)

Current Rating:
(3.6)

Comments

nicely written good information and review. how old was this pt?

Posted By Thomas Weidman / Posted At 5/28/05 3:30 PM

Good patient presentation and review. It would have been nice to add a DDx to this case though. Having just finished a book on the black death a bulbus (sp?) was my first thought. Several other disease can cause similar findings in the axilla, cat scratch being one of them. Would be nice to learn of the results, keep us posted.

Posted By Brian Guadagno / Posted At 5/29/05 9:41 PM

What was it about this patient that brought Hodgkins Lymphoma to your preceptor's mind? Did your patient have any of the "typical"symptoms of cancer that we all learn? Keep us posted.

Posted By Marcela Mcdonald / Posted At 5/30/05 1:29 AM

I also would have jumped to infectious causes of LAD before CA as well, considering the stint in Bermuda was he exposed to any different tropical parasites or pests? Also did you consider a chest x-ray? You could have quickly identified a mediastinal mass consistent with a lymphoma without waiting for the path.

Posted By Stacey Olney / Posted At 5/30/05 10:01 AM

From what you described with none of the classical signs of CA, I am surprised that your preceptor's first item on the differential was Hodgkin's Lymphoma. The patient denied weight loss, fever, night sweats, etc. I agree with the above comments that the patient was in a tropical location for some time and could have been exposed to unusual infections. Since the bx could not be done until later, were other tests done such as CBCs, ESRs, metabolic panels, Ca2+ done so that they would be available for analysis on Monday as well?

Posted By Jed Peterson / Posted At 5/31/05 7:54 PM

I agree, getting a chest x-ray is an easy, relatively cheap test that can lend more support to the diagnosis. However, given that the referal is already made to the surgeon, a chest x-ray may not change the management of the patient from the primary care's perspective.

Posted By Duc To / Posted At 5/31/05 7:57 PM