When only Biopsy can Provide an Answer

Introduction: Peripheral lymphadenopathy in children is generally benign and self-limited. However, it can be a manifestation of serious underlying disease, so differential diagnosis is essential.

Case report: We report a case of a 4-year-old male, previously healthy, presented to the paediatric emergency department with a painless right cervical tumefaction, with about one month of evolution. Fever and weight loss were denied, as well as previous illness and contact with cats. Two antibiotic therapy cycles were performed previously, due to likely bacterial infection, without showing clinical improvement.

On physical examination: Good overall appearance. Rosy faced and hydrated. Right cervical tumefaction (5*3cm, painless to palpation, without local inflammatory signs). Without other palpable lymphadenopathies or hepatosplenomegaly.

Laboratory tests revealed: hemoglobin 11,8g/dL; neutrophil series count 8,74x109/L; platelet count 376 x109/L; no changes in kidney and liver function; C-reactive protein and Erythrocyte sedimentation rate were negatives.

Due to the persistence of tumefaction, hospitalization was decided for etiological investigation. Serological tests for HIV, CMV, Toxoplasmosis and Bartonella henselae were all negative. Tuberculin skin testing was negative. Chest radiograph showed no changes. Abdominal ultrasonography with two lymphadenopathies of 11 and 15mm in retroperitoneal space, without hepatoesplenomegaly. Cervical ultrasonography revealed a hypoecoggenic nodular image of regular and well-defined contour in the right jugulo-digastric chain, measuring 41mmx16mm, and showing no adipose hilum, suggesting lymphadenopathy. Aditionally, there were other smaller lymphadenopathies.

Although studies have suggested a benign etiology, due to persistence of tumefaction, a biopsy of the lesion was performed and indicated Burkit Lymphoma.

Conclusion: With this work, the authors intend to highlight that if after four weeks of observation and/or empiric therapy, the diagnosis remains uncertain and the lymph node has not regressed in size, a biopsy should be warranted, as only this can confirm or exclude for sure a diagnosis.