SELF ASSESSMENT QUESTIONS A 60 year old woman with axillary mass

A 60 year old women, a resident of Delhi, presented to the medical outdoor department of Lady Hardinge Medical College with complaints of recurrent fever accompanied by chills, rigor, headache, and malaise. She had no complaints suggestive of respiratory or urinary tract involvement. She had been treated with antimalarials (chloroquine and sulfadoxinepyrimethamine), however, she continued to be febrile. Subsequently, the patient reported a painful lump in the right axilla accompanied by pain in the right upper limb. There was no history of nipple discharge or breast lump, local injury to the limb, insect bite, haemoptysis, or chest pain, loss of weight, bleeding diathesis, any skin rash, and urinary or bowel complaints. Past and family history were non-contributory. Physical examination revealed a conscious middle aged women, with normal pulse rate (80 beats/min) and blood pressure (140/80 mm Hg). Respiratory rate was 26 breaths/min and her body temperature was 39°C. She was anaemic; however, there was no jaundice, cyanosis, clubbing, and oedema. Bilateral axillary lymph nodes were enlarged, measuring 2 × 2 cm, firm, tender, and mobile. There was no lymph node enlargement elsewhere on the body. There was a tender, reddish streak on the medial aspect of right arm. Examination of breast and other systems was normal. With provisional diagnoses of streptococcal lymphangitis, tubercular lymphadenitis, secondaries from internal malignancy and primary lymphoma, the patient was subject to further investigations. Investigations revealed a haemoglobin of 128 g/l, total lymphocyte count of 7800/mm, erythrocyte sedimentation rate of 30 mm/hour with eosinophilia (22% with an absolute count of 900/mm). Peripheral smear revealed no haemoparasites. All other investigations including chest radiography, a sonographic study of the abdomen, Mantoux test, and urinary and blood cultures were normal. Serum IgE concentrations were not measured as the investigation was not available to us when the patient presented. The results of a fine needle aspiration from one of the right axillary lymph nodes are shown in fig 1. Aspiration from the left axillary nodes revealed only non-specific lymphadenitis.