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Case of the Month: Non-Tender Neck Mass in an Adolescent

By Samuel Tomlinson, MS3

Clinical history

18-year-old male who presented with a several week history of a large, firm, non-tender mass on the right side of the neck. A one-week course of Augmentin produced minimal response. Patient is uncertain whether the mass appeared gradually or acutely, and he denies dysphagia, odynophagia, hoarseness, sore throat, weight loss, fatigue, and constitutional symptoms.

Past medical history (PMH)

Patient is previously healthy with no significant past medical history. Past surgical history is notable for status-post tonsillectomy and adenoidectomy at age 8. Patient denied alcohol or tobacco use, exposures (cats, TB, international travel, etc.), cancer history, radiation treatments, and prior neck injuries. There are no known food/drug allergies.

Recent history

Upon presentation, physical exam revealed a 12 x 7 cm semi-firm mass in right nodal level II. The mass was fixed and non-tender without overlying skin changes. CT scan was consistent with bilateral cervical lymphadenopathy ranging from 2.9-4.3 cm (Figure 1).

FNA was performed, and cytology revealed bland histiocytes engulfing lymphocytes. Excisional right cervical lymph node biopsy revealed characteristic emperipolesis (Figure 2), small follicles with germinal centers and mantle zones (Figure 3), and regions of increased plasma cells. Immunohistochemical stains revealed diffuse positivity of histiocytes for S-100 and CD68, and negativity for PLAP. 

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