What is the significance of axillary lymphadenopathy in a patient with positive Cytomegalovirus (CMV) Immunoglobulin G (IgG)?

From the Guidelines

Lymphadenopathy in the axilla with a positive CMV IgG test is likely unrelated to the past CMV infection and should be evaluated separately, with a focus on potential causes such as breast cancer, lymphoma, or local infections. The presence of a positive CMV IgG test indicates past exposure to cytomegalovirus, but this does not necessarily imply an active infection 1. The axillary lymphadenopathy should be assessed through physical examination, additional blood tests (including CMV IgM to check for active infection), and possibly imaging studies like ultrasound, as recommended by the NCCN Panel 1. Some key points to consider in the evaluation of axillary lymphadenopathy include:

• The NCCN Panel recommends complete clinical evaluation to assess for other sites of adenopathy and potential non-breast etiologies of adenopathy 1
• Age-appropriate diagnostic imaging, such as ultrasound with mammogram for those ≥30 years of age, and ultrasound for those <30 years of age, should be performed 1
• A core needle biopsy is recommended for palpable axillary mass that is suspicious or highly suggestive on imaging 1
• The most recent and highest quality study, published in 2022, suggests that FDG-PET/CT can detect axillary lymphadenopathy, but its use as the initial imaging test is not supported by relevant literature 1
• Ultrasound is the modality of choice for imaging of the axilla, as it permits visualization of level I and II nodes routinely, and can guide FNA or core biopsy to confirm metastatic disease 1 Given the potential causes of axillary lymphadenopathy, it is essential to prioritize a thorough evaluation to determine the underlying cause, and a watch-and-wait approach with follow-up, antibiotics if bacterial infection is suspected, or biopsy if there are concerning features may be recommended by the doctor.

From the Research

Lymphadenopathy Axilla with CMV IgG Positive

• Lymphadenopathy is a condition characterized by the enlargement of lymph nodes, which can be caused by various factors including infections, malignancies, and autoimmune disorders 2.
• The presence of CMV IgG antibodies indicates a past infection with cytomegalovirus, which can cause lymphadenopathy in some cases.
• Axillary lymphadenopathy, in particular, can be caused by a variety of factors, including breast cancer, lymphoma, and infections such as CMV 3.
• The diagnosis of lymphadenopathy typically involves a combination of physical examination, laboratory tests, and imaging studies, with biopsy being the gold standard for definitive diagnosis 2.
• In cases where lymphadenopathy is detected on screening mammography, fine-needle aspiration cytology (FNAC) and excision biopsy may be necessary to determine the underlying cause 3.
• Valganciclovir, an antiviral medication, has been shown to be effective in preventing CMV reactivation in immunocompromised patients, including those receiving alemtuzumab-based therapy 4.
• However, the relationship between CMV IgG positivity and lymphadenopathy is not fully understood, and further evaluation is necessary to determine the underlying cause of lymphadenopathy in individual cases.

Evaluation and Management

• Patients with lymphadenopathy should undergo a thorough evaluation, including a physical examination, laboratory tests, and imaging studies, to determine the underlying cause 2.
• The management of lymphadenopathy depends on the underlying cause, and may involve antibiotics, antiviral medications, or other treatments as necessary.
• In cases where CMV is suspected to be the cause of lymphadenopathy, antiviral medications such as valganciclovir may be considered 5, 6.
• However, the use of valganciclovir or other antiviral medications should be guided by the results of diagnostic tests and the clinical presentation of the patient.