Differential Diagnosis

The patient presents with a history of swollen tonsils with white spots or patches, bilateral neck lymphadenopathy, and subsequent swelling at previously enlarged lymph node sites, despite claiming to be HIV negative without documentation. Given the clinical presentation and the results of the HIV tests, the following differential diagnoses are considered:

• Single Most Likely Diagnosis
  • Acute Infectious Mononucleosis (Mono): This condition, often caused by Epstein-Barr virus (EBV), can present with swollen tonsils, white patches, and lymphadenopathy, which matches the patient's initial symptoms. The resolution of some symptoms with antibiotics could be due to a secondary bacterial infection, and the persistence of lymph node swelling could be consistent with the prolonged course of mono.
• Other Likely Diagnoses
  • Streptococcal Pharyngitis: The initial presentation of swollen tonsils with white spots or patches and lymphadenopathy could be indicative of streptococcal pharyngitis, which was partially treated with Amoxicillin.
  • Reactive Lymphadenopathy: This is a condition where lymph nodes become swollen in response to an infection or inflammation in the body, which could explain the lymphadenopathy and its resolution and subsequent swelling in response to various stimuli.
• Do Not Miss Diagnoses
  • HIV Infection (Early Stage): Despite the patient's claim of being HIV negative and the non-reactive HIV tests, it's crucial not to miss early HIV infection, especially if the patient has engaged in high-risk behaviors. Early HIV can present with similar symptoms, and the window period (the time between potential exposure to HIV and when the test can accurately detect the presence of the virus) must be considered.
  • Lymphoma: Although less likely, lymphoma (such as Hodgkin lymphoma) can present with lymphadenopathy and should be considered, especially if lymph node swelling persists or grows.
• Rare Diagnoses
  • Toxoplasmosis: This parasitic infection can cause lymphadenopathy and, in rare cases, might present similarly to the patient's symptoms, especially if the patient is immunocompromised.
  • Cytomegalovirus (CMV) Infection: CMV can cause a mononucleosis-like syndrome with lymphadenopathy, particularly in immunocompromised individuals or those with no prior exposure to CMV.

Each of these diagnoses is considered based on the patient's symptoms, the natural history of the diseases, and the importance of not missing potentially life-threatening conditions. Further diagnostic workup, including imaging studies, additional laboratory tests, and potentially a lymph node biopsy, may be necessary to determine the underlying cause of the patient's symptoms.