This case study of a 75-year-old female patient who presented with a suspicious neck mass. Extensive diagnostic efforts, including histopathology, PET-CT imaging, and hematopathology consultation, revealed a complex presentation in which the first biopsy was positive for actinomycosis without tumor cells, while a second more profound biopsy revealed and confirmed the coexistence of diffuse large B – cell lymphoma. This case emphasizes the importance of a multidisciplinary approach to diagnosis and treatment.
Table of Contents
1. Abstract
2. Case Presentation
3. Discussion
4. Conclusion
Objectives and Topics
This case study examines the diagnostic and therapeutic complexities associated with managing a 75-year-old patient who presented with symptoms mimicking a benign infection, which was ultimately diagnosed as diffuse large B-cell lymphoma coexisting with actinomycosis. The study highlights the necessity of a multidisciplinary approach in geriatric oncology.
- Evolution of diagnostic challenges in oropharyngeal pathology
- Clinical differentiation between infectious processes and malignancy
- Impact of comorbid actinomycosis on initial biopsy outcomes
- Importance of comprehensive histological and PET-CT evaluation
- Strategies for managing advanced head and neck tumors in elderly patients
Excerpt from the Book
Case Presentation:
A 75-year-old patient presented in our office with a one-month history of throat irritation and tonsil discomfort associated with difficulty swallowing, voice changes, left ear pain, and mild jaw pain. She reported moderate pain of 3 on a scale of 0-10. The patient reported that she had completed a previous course of prednisone and amoxicillin clavulanate antibiotics prescribed by her primary care provider, with no relief in symptoms. Upon initial examination, the patient expressed concern regarding a noticeable mass on the left side of her neck. Evaluation revealed significant tonsillar asymmetry and hypertrophy, particularly on the left side, with notable yellowish exudate resembling tumoral exudate. Endoscopic examination of the oral cavity revealed an enlarged left tonsil irregular ulcer border enlargement with copious amounts of thick particulate material in the crypts. The right tonsil appeared normal. The patient was diagnosed as a case of acute recurrent throat discomfort with regional lymphadenitis.
The unusual appearance of the tonsil, coupled with the patient's prior cancer history, raised immediate concerns for a malignant process, prompting further diagnostic investigations. A throat culture was obtained, describing normal respiratory flora, blood work showed CEA level of 0.981ng/ml and a sedimentation rate of 95 mm/hr. The patient underwent a computed tomography of the neck with contrast (Figure 2), which described a left oropharyngeal mass lesion extending to the base of the tongue and supraglottic larynx, with malignancy suspected; numerous non enlarged lymph nodes were identified bilaetrically. The diagnostic journey was further complicated by initial biopsy findings. A biopsy conducted revealed necrotic tissue and colonies of Actinomyces spp, without evidence of malignancy. This led to initial treatment with doxycycline for the infectious component. However, persistent clinical suspicion led to a second evaluation of a PET-CT.
Summary of Chapters
Abstract: Provides an overview of the clinical journey of a 75-year-old patient where a suspected tonsillar malignancy was complicated by a secondary actinomycosis diagnosis.
Case Presentation: Details the clinical symptoms, the patient's history, the diagnostic steps including initial biopsy pitfalls, and the identification of diffuse large B-cell lymphoma.
Discussion: Analyzes the epidemiology of the lymphoma, the diagnostic difficulties posed by comorbid infections (actinomycosis), and the importance of differential diagnosis in elderly patients.
Conclusion: Reaffirms the necessity of a multidisciplinary team approach and personalized medical plans to improve outcomes in complex head and neck cancer cases.
Keywords
Diffuse Large B-cell Lymphoma, Actinomycosis, Oropharyngeal Cancer, Tonsillar Asymmetry, Multidisciplinary Approach, Geriatric Oncology, Biopsy, PET-CT, Head and Neck Lymphoma, Histopathology, Diagnostic Complexity, Oral Pathology, Oncology, Lymphocyte, Survival Rate
Frequently Asked Questions
What is the primary focus of this clinical case study?
The study focuses on the diagnostic and therapeutic journey of a 75-year-old patient with an oropharyngeal mass, showcasing the difficulties of diagnosing malignancy when co-occurring with an infectious condition like actinomycosis.
What are the primary themes discussed in the paper?
It covers diagnostic challenges, the interplay between infectious and malignant diseases, the role of multidisciplinary teams in healthcare, and treatment strategies for geriatric patients.
What is the core research goal?
The goal is to emphasize how complex clinical presentations, specifically overlapping symptomatic infectious and malignant processes, require comprehensive evaluations to ensure patient safety and effective care.
Which scientific methodology was utilized?
The researchers utilized a clinical case study approach, documenting the patient's end-to-end evaluation including blood work, CT imaging, PET-CT scans, and multiple biopsies with immunohistochemical staining.
What topics are covered in the main body?
The main body examines the specific case history, diagnostic evaluation results, discussion of current medical statistics regarding diffuse large B-cell lymphoma, and the differential diagnosis of tonsillar tumors.
Which keywords define this work?
Key terms include Diffuse Large B-cell Lymphoma, Actinomycosis, Oropharyngeal Cancer, Multidisciplinary Approach, and Geriatric Oncology.
How does the presence of Actinomyces impact the diagnostic process?
It complicates the diagnosis significantly because the first biopsy only identified the infection, yielding a false negative for malignancy, which delayed the confirmation of the actual tumor.
Why is a multidisciplinary approach critical for this patient?
Given the complexity of the patient's histology and the need for systemic chemotherapy tailored to specific health needs, a collaborative team of oncologists, ENT specialists, and hematologists is essential.
What was the specific histological finding of the second biopsy?
The second biopsy confirmed a diffuse large B-cell lymphoma with an activated B-cell phenotype, characterized by specific CD20, BCL6, and BCL2 positivity.
What is the significance of the "negative p16 immune stain" mentioned?
It helped the clinicians steer the diagnosis away from HPV-related cancers, which are commonly treated in primary care, towards more specialized oncological malignancy evaluations.
- Quote paper
- Pablo Arango (Author), Manuel Medina Suarez (Author), Amanda Menendez (Author), Manuel Javier Medina Rodriguez (Author), Helen Aguila Cid (Author), 2025, Integrated Diagnostic and Medical Management of Concurrent Actinomycosis and Diffuse Large B-Cell Lymphoma of the Tonsil Through ENT Evaluation, Munich, GRIN Verlag, https://www.grin.com/document/1582477
