Document Type

Conference Proceeding

Publication Date

5-1-2026

Abstract

Introduction The differential diagnosis for a new neck mass is broad and includes malignant, infectious, and autoimmune etiologies. A systematic approach incorporating history, physical examination, and diagnostic testing is essential when developing and narrowing down a differential. Case Presentation A 52-year-old man with a history of diabetes, asthma, ankylosing spondylitis on weekly etanercept, and GERD presented with a 2-day history of painless right-sided neck swelling. He denied fever, chills, weight loss, night sweats, dysphagia, dyspnea, cough, recent illness, or constitutional symptoms aside from mild fatigue. He had recently returned from a 1.5- month trip to Bangladesh and had self-discontinued etanercept during travel, restarting it one month prior to presentation. He reported no tobacco, alcohol, or drug use. On examination, he appeared well. Vital signs were normal. The neck exam revealed multiple mobile, rubbery, nontender lymph nodes along the anterior cervical chain. No axillary or inguinal lymphadenopathy was identified. Cardiac, pulmonary, abdominal, neurologic, and skin examinations were unremarkable. Initial labs demonstrated mild normocytic anemia (Hgb 11.5 g/dL, MCV 81 fL) and no leukocytosis. Basic metabolic panel, liver chemistries, and albumin were within normal limits. Contrast-enhanced CT of the neck revealed extensive right cervical chain, supraclavicular, and mediastinal lymphadenopathy, including a dominant right level III lymph node measuring 3.1 cm. Additional findings included heterogeneous thyroid nodules in the right lobe up to 2.1 cm. CT chest revealed no acute pulmonary disease, with only a benign calcified granuloma in the right upper lobe. Notable findings on CT abdomen included diverticulosis and benign splenic granulomatous calcifications without splenomegaly. Given the patient's travel history in conjecture with granulomas in the lung and spleen, a Quantiferon-TB Gold test was ordered and found to be positive. Further workup included serum protein electrophoresis which revealed no monoclonal spike and normal kappa:lambda ratio. Immunoglobulin levels were within normal reference ranges. Viral serologies showed positive IgG for CMV and EBV with negative IgM, consistent with remote infection. Autoimmune studies including thyroglobulin antibodies were unremarkable. TSH was normal (3.86 μIU/mL). HIV screening was negative. Notably, a Quantiferon-TB Gold test returned positive. The patient underwent excisional biopsy of a right cervical lymph node. Pathology revealed metastatic papillary thyroid carcinoma. Discussion In this patient, an infectious etiology, particularly tuberculous lymphadenitis, was initially high on the differential. He had multiple risk factors for mycobacterial disease, including recent travel to an endemic region, immunosuppression due to etanercept therapy, and the presence of calcified granulomas on imaging. A positive IGRA further heightened concern for tuberculosis. However, a positive IGRA alone does not distinguish latent infection from active disease, and clinical correlation is required. The absence of systemic symptoms and the lack of pulmonary findings were not classic for extrapulmonary TB. Ultimately, the patient was found to have metastatic papillary thyroid carcinoma. This outcome underscores that patients with infectious risk factors may still harbor an underlying malignancy. The unexpected diagnosis reinforces the need to actively guard against anchoring and to continually re-evaluate working diagnoses as new information emerges.

Comments

American College of Cardiology Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2026 Resident and Medical Student Day, May 1, 2026, Troy, MI

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