Differential Diagnosis for Chronic Cervical Lymphadenitis
Single Most Likely Diagnosis
- Cat-Scratch Disease (Bartonella henselae infection): Although Bartonella serology was negative, it's essential to consider that serology may not always be positive, especially if the test was done early in the course of the disease. The presence of necrotizing granulomatous infection on biopsy is consistent with this diagnosis. However, given the serology result, this might be less likely than initially thought, but it remains a consideration due to the clinical presentation and biopsy findings.
Other Likely Diagnoses
- Atypical Mycobacterial Infection: Given the necrotizing granulomatous infection on biopsy and the lack of response to standard antibiotics, an atypical mycobacterial infection is a plausible diagnosis. The negative PPD and interferon-gamma release assay do not entirely rule out this possibility, as these tests can have variable sensitivity.
- Lymphoma: Although less common in this age group, lymphoma can present with chronic lymphadenitis that does not respond to antibiotics. The recent hospitalization and lack of response to treatment increase the suspicion for a more serious underlying condition like lymphoma.
Do Not Miss Diagnoses
- Tuberculosis (TB): Despite the negative PPD and interferon-gamma release assay, TB is a critical diagnosis not to miss due to its potential severity and the need for specific treatment. False negatives can occur, especially in very young children or in those with severe forms of TB.
- Malignancy (including Leukemia): Any condition that does not respond to standard treatment and presents with systemic symptoms like fever warrants a thorough investigation for malignancy. Although less likely, the potential consequences of missing such a diagnosis are severe.
Rare Diagnoses
- Kikuchi-Fujimoto Disease: A rare, self-limiting condition that can present with cervical lymphadenitis and fever. It's more common in Asian populations and typically affects young women, but it can occur in any demographic.
- Rosai-Dorfman Disease: A rare histiocytic disorder that can cause lymphadenopathy, which may be accompanied by systemic symptoms. It's essential to consider this in the differential due to its unique presentation and the need for specific diagnostic tests.
- Castleman Disease: A rare disorder that can cause lymphadenopathy, fever, and other systemic symptoms. It's crucial to consider this diagnosis due to its potential for severe complications if not treated appropriately.