The diagnostic uncertainty of a 27 year old woman

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 A 27 year old woman presented to our OPD with the complaints of 
Fissured tongue since 6 months
Angular chelitis since 6 months 
Loss of appetite since 6 months 
Weight loss over 6 months 


She first reported to our outpatient unit with  oral ulcerations, tongue fissures , angular chelitis  since the past 6 months. She also reported  loss of weight of around 10 kgs over the last 6 month along with low grade intermittent fever over the past few months.
The following month, she again presented with the complaints of bilateral non tender cervical lymphadenopathy. She reported that these cervical swellings would intermittently subside by itself. 
She however had no complaints of cough, night sweats, eczema, joint pains. 




On examination:
Thin built woman
Pulse Rate - 70bpm
Blood Pressure - 110/70mmhg
Respiratory Rate - 20 cycles per minute
Temperature - 98.6 F
GRBS - 100mg/dl
Weight - 34kgs
Height - 150cms

Pallor +
Lymph Node examination:
Palpable submental, submandibular and cervical lymph nodes, non tender, firm in consistency,  submandibular lymph node measuring 3 x 2 cms. 

Cardiovascular System - S1, S2 + on auscultation 
Respiratory System - 
Bilaterally clear on auscultation 
Nervous system - no abnormality detected 
Per Abdomen - 
Soft
Non tender
Bowel sounds +

Provisional Diagnosis: 
27 year old woman with bilateral multiple lymph nodal enlargement secondary to 
? Tuberculosis
? Sarcoidosis
?Malignancy 
Investigations:

ECG:


Chest Xray PA view:

Hemogram revealed Hemoglobin of 8.4g/dl
MCV - 69
MCH - 21.7
TLC - 6400 cells/cumm
Platelet count - 3.71 lakhs/cumm

Peripheral smear showing microcytic hypochromic
Retic count - 0.8%
Corrected Retic count - 0.5, Retic index - 0.33 --> Hypoproliferative
Serum Ferritin - 15 micrograms per liter

Ultrasonography of neck:




 FNAC of her cervical lymph node was done which revealed Reactive lymphadenitis. It was even sent to CBNAAT in suspicion of TB and which was also negative.

IGRA - negative 

After sending her ANA profile it turned out with be negative as well.

We decided to do a lymph node biopsy after convincing the patient and her husband.

After taking opinion from the oncologists at MNJ, they suspected Reactive lymphadenitis however since the lymph nodes have been persistent since more than 6 months they advised for another lymph nodal biopsy  

Diagnosis:

A 27 year old woman with bilateral multiple cervical lymphadenopathy secondary 
? Sarcoidosis
?Malignancy
Iron Deficiency Anemia

Discussion:





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