What is the appropriate management for a female patient with a one-month history of painless right paracervical lymph node enlargement that has become painful over the last 5 days?

Management of Painful Paracervical Lymph Node Enlargement

This patient requires immediate tissue diagnosis via excisional biopsy given the high-risk features: node enlargement >1.5 cm persisting >4 weeks, recent change in character (painless to painful), and paracervical location. 1, 2

Initial Risk Stratification

The clinical presentation contains multiple concerning features that mandate aggressive workup:

• Duration >4 weeks places this patient at significantly increased risk for malignancy or chronic infection, as nodes ≥1.5 cm persisting ≥2 weeks without significant fluctuation warrant immediate investigation 1
• The transition from painless to painful over 5 days could represent rapid growth (concerning for aggressive lymphoma), secondary infection of a malignant node, or inflammatory changes 1, 2
• Paracervical location is anatomically concerning and requires thorough evaluation 2

Critical Historical and Physical Examination Elements

Immediately assess for the following high-risk features:

• Age >40 years, tobacco use, alcohol abuse, or HPV-related risk factors mandate aggressive workup 2
• B symptoms (fever >38°C, drenching night sweats, unintentional weight loss >10% body weight in 6 months) strongly suggest lymphoma and require PET/CT imaging 1, 2
• Node characteristics: Size, texture (firm/hard vs. soft), mobility (fixed vs. mobile), presence of matted nodes, overlying skin changes (ulceration, erythema, violaceous discoloration) 1, 2
• Immunosuppression history including HIV status, transplant history, or chronic immunosuppressive medications 2

Diagnostic Imaging

Order CT neck with IV contrast immediately to evaluate deep extension, assess for additional lymphadenopathy, and characterize the node 2. Consider ultrasound to assess for:

• Loss of fatty hilum (highly suspicious for malignancy) 1
• Round rather than oval shape 1
• Heterogeneous echogenicity 1
• Central necrosis 1

Laboratory Evaluation

Obtain the following baseline studies:

• Complete blood count with differential to assess for atypical lymphocytosis (viral), leukemia, or cytopenias 2, 3
• ESR and serum albumin 2
• HIV testing, especially in younger patients or those with risk factors 2
• Tuberculin skin test or interferon-gamma release assay to distinguish tuberculous from nontuberculous mycobacterial disease, particularly if the node is unilateral 1, 3
• HBV and HCV testing 2

Tissue Diagnosis Strategy

Proceed directly to excisional biopsy rather than fine-needle aspiration (FNA) in this case given the high-risk features and need for definitive diagnosis 1, 2. While FNA is accurate and economical for initial evaluation, excisional biopsy remains the gold standard and should not be delayed in high-risk presentations 1, 2.

If lymphoma is suspected based on B symptoms or imaging, obtain baseline PET-CT before biopsy to facilitate staging 2. Send fresh tissue in saline for:

• Flow cytometry 3
• Immunohistochemistry (CD20, CD10, Ki-67) 3
• Cytogenetics 3
• Mycobacterial culture if granulomatous disease is identified 3

Referral Pathways

Immediate hematology-oncology referral is indicated if any of the following are present:

• Nodes >1.5 cm 2
• Hard or matted nodes 2
• B symptoms 2
• Immunosuppression history 2

ENT/surgical oncology referral is necessary for suspected head and neck primary malignancy or to perform excisional biopsy 2.

Critical Pitfalls to Avoid

• Do NOT empirically treat with antibiotics in the absence of clear signs of acute bacterial infection (rapid onset, fever, overlying erythema, warmth) 1. The transition to pain does not automatically indicate bacterial superinfection.
• Do NOT mistake nontuberculous mycobacterial (NTM) lymphadenitis for bacterial infection and treat with inappropriate antibiotics—this is a common error 1. NTM typically presents as unilateral, generally non-tender nodes that may become violaceous 1, 3.
• Do NOT delay biopsy for prolonged observation in this case—the node has already been present for one month, which exceeds the 2-4 week observation period recommended for benign-appearing lymphadenopathy 4, 5.
• Do NOT perform incisional biopsy if head and neck malignancy is suspected—this can compromise subsequent surgical management 6.

Differential Diagnosis Considerations

The most concerning etiologies given this presentation include:

• Lymphoma (Hodgkin or non-Hodgkin): Painless enlargement with recent painful change could represent rapid growth or necrosis 1, 2
• Metastatic carcinoma: Particularly head and neck primary, thyroid, or lung 2, 6
• Mycobacterial infection: Either tuberculous (more common in adults >90% of cases) or nontuberculous (typically MAC, usually non-tender but can have variable presentation) 1, 3
• Infectious mononucleosis (EBV): Can cause cervical lymphadenopathy, though typically bilateral and associated with constitutional symptoms 1, 3