Progressive Constitutional Symptoms with Lymphadenopathy in a Young Woman

Case at a Glance

A 30-year-old previously healthy female presented with a 6-month history of progressive constitutional symptoms including daily headaches, severe fatigue, night sweats, and painless cervical lymphadenopathy, concerning for possible hematologic malignancy.

Patient's Story

The patient reported a gradual onset of debilitating symptoms over 6 months, including daily headaches, complete loss of appetite with nausea, and severe fatigue. She experienced night sweats and intermittent chills without fever. Upper back pain was severe enough to cause nightmares, with radiation to the lung area. She developed a persistent dry cough without preceding viral illness and noticed easy bruising. Physical examination revealed a firm, painless, palpable lymph node on the left side of her neck. The patient also reported muscle twitches occurring approximately every 30 minutes. She denied alcohol use, substance use, or current medications.

Initial Assessment

Physical examination revealed a firm, non-tender cervical lymph node measuring approximately 12mm. The patient appeared fatigued but was alert and oriented. Vital signs were stable. Initial imaging included chest X-ray and brain/spine MRI, both reported as normal. Cervical lymph node ultrasound confirmed a 12.1mm x 10mm node, initially interpreted as likely reactive.

The Diagnostic Journey

Laboratory workup revealed concerning trends with steady decline in platelet and white blood cell counts over the preceding year, though values remained within normal limits. Two EEGs demonstrated generalized slow wave activity. The patient was initially reassured that symptoms were likely unrelated, with sleep study recommended as the next step. However, the constellation of symptoms - including B-symptoms (night sweats, weight loss), painless lymphadenopathy, cytopenias, and constitutional symptoms - raised concern for hematologic malignancy among consulting physicians.

Final Diagnosis

Case pending further workup. Differential diagnosis includes lymphoma (Hodgkin's or aggressive non-Hodgkin's), leukemia, infectious causes (EBV, CMV, HIV), autoimmune conditions, or other systemic disorders.

Treatment Plan

Recommended urgent referral to hematology-oncology for comprehensive evaluation including: lymph node biopsy, contrast CT imaging of head/neck/chest/abdomen/pelvis, complete blood count with manual differential and peripheral smear, flow cytometry, inflammatory markers (ESR, CRP), LDH, uric acid levels, and infectious disease screening (EBV, CMV, HIV). PET-CT scan considered for staging if malignancy confirmed.

Outcome and Follow-up

Patient education provided regarding warning signs requiring immediate medical attention including sudden lymph node changes, worsening dyspnea, profuse night sweats, or unusual bleeding. Urgent subspecialty referral arranged with instructions for close monitoring pending definitive diagnosis.