What is the underlying cause of a maintenance technician's chronic abdominal pain, cervical and inguinal adenopathy, and radicular pain into the testicles, with a history of viral meningitis, Bell's palsy, and negative HIV, Hep A, B, C testing, currently on Bactrim-DS (Trimethoprim/Sulfamethoxazole) and Cipro (Ciprofloxacin)?

Diagnostic Approach to Chronic Lymphadenopathy with Abdominal and Testicular Pain

This patient requires urgent lymph node biopsy to exclude lymphoma, as the persistent hilar and mediastinal lymphadenopathy with residual thymic tissue raises significant concern for malignancy that cannot be ruled out by imaging alone.

Primary Diagnostic Considerations

The constellation of chronic cervical and inguinal lymphadenopathy (3+ years), persistent right hilar lymph node enlargement, residual anterior mediastinal soft tissue density concerning for lymphoma, and chronic abdominal pain with RLQ lymph nodes strongly suggests an underlying lymphoproliferative disorder rather than an infectious etiology 1.

Key Imaging Findings Requiring Action

• Mediastinal abnormalities: The "residual thymic tissue" with lymphoma not ruled out, combined with progressively enlarging right hilar lymph node on serial CTAs, mandates tissue diagnosis 1
• Abdominal findings: RLQ lymph nodes with possible terminal ileitis and periprostate/seminal vesicle inflammation suggest either lymphomatous involvement or chronic inflammatory process 2
• Testicular findings: Bilateral varicoceles with microlithiasis and epididymal cysts may contribute to radicular testicular pain but do not explain systemic lymphadenopathy 2

Addressing the Testicular Pain Component

The radicular pain into testicles (R>L) with bilateral varicoceles and epididymal cysts identified on ultrasound requires consideration of chronic epididymitis versus referred pain from other sources 1.

Epididymitis Evaluation

• Current antibiotic coverage: The patient is already on Bactrim-DS and completed Cipro, which would adequately treat common bacterial causes (Enterobacterales, C. trachomatis, N. gonorrhoeae) 2
• Persistent symptoms despite antibiotics: This argues against acute bacterial epididymitis and suggests either chronic pelvic pain syndrome or referred pain from intra-abdominal pathology 2
• Chronic prostatitis/pelvic pain syndrome: Approximately 50% of men with this condition have urethral inflammation without identifiable pathogens, which could explain persistent symptoms 2

Critical Distinction

The soft tissue stranding around seminal vesicle/prostate noted on CT may represent chronic prostatitis, but given the systemic lymphadenopathy, this could also represent lymphomatous infiltration requiring tissue diagnosis 2.

Abdominal Pain Analysis

The chronic RLQ to RUQ pain with sensation of pelvic fullness, combined with CT findings of possible terminal ileitis and prominent RLQ lymph nodes, creates a differential including:

• Lymphoma (most concerning given systemic adenopathy and mediastinal findings)
• Inflammatory bowel disease (terminal ileum involvement)
• Chronic infectious process (though HIV, Hep A/B/C negative)
• Genitourinary tuberculosis (GUTB) - must be considered given chronic course and multisystem involvement 2

Tuberculosis Consideration

GUTB can affect all genitourinary organs and presents with non-specific symptoms including abdominal pain, though the patient has no known TB exposure 2. The history of "viral meningitis" 6-7 years ago raises the question of whether this could have been tuberculous meningitis, though drug-induced aseptic meningitis from Bactrim is also possible 3, 4.

Immediate Recommended Actions

Prioritize tissue diagnosis before further imaging:

1. Excisional lymph node biopsy of most accessible enlarged node (cervical preferred) for:

   • Flow cytometry
   • Immunohistochemistry
   • Mycobacterial and fungal cultures
   • Molecular studies if lymphoma suspected 1

2. If biopsy confirms lymphoma: Proceed with PET-CT for staging rather than additional CT scans 1

3. If biopsy negative for malignancy, pursue:

   • TB testing (interferon-gamma release assay preferred over skin test given possible prior BCG)
   • Three early morning urine specimens for acid-fast bacilli if GUTB suspected 2
   • Colonoscopy with terminal ileum biopsy if inflammatory bowel disease suspected

Management of Current Symptoms

Discontinue Bactrim-DS Immediately

• Drug-induced aseptic meningitis risk: Given history of "viral meningitis" and current Bactrim use, consider that previous episode may have been drug-induced 3, 4
• Inadequate coverage: If chronic bacterial prostatitis/epididymitis were present, the prolonged antibiotic courses already completed would have resolved symptoms 2

Symptomatic Management Pending Diagnosis

• Testicular pain: Scrotal support, NSAIDs for inflammation 1
• Abdominal pain: Avoid further empiric antibiotics until diagnosis established
• Monitor for B symptoms: Fever, night sweats, weight loss suggesting lymphoma progression

Common Pitfalls to Avoid

• Ordering more imaging without tissue diagnosis: The hematology/oncology consultant appropriately wants clarification, but the answer is biopsy, not another CT scan 1
• Attributing all symptoms to infection: The 3-year duration, negative infectious workup, and failure to respond to multiple antibiotic courses argues against primary infectious etiology 2
• Overlooking drug-induced complications: Bactrim can cause aseptic meningitis and should be discontinued given the prior "viral meningitis" history 3, 4
• Delaying lymphoma workup: Progressively enlarging hilar lymph node with mediastinal abnormality concerning for lymphoma requires urgent tissue diagnosis to prevent disease progression and preserve treatment options 1

The underlying cause remains undiagnosed, but lymphoma is the most concerning possibility requiring immediate exclusion through tissue biopsy before any additional imaging studies.