Navigating Conflicting Medical Opinions: Lymphadenopathy vs. Cellulitis

The initial orthopedic consultation indicated lymphadenopathy, and the follow-up visit diagnosed cellulitis?

Hello Doctor, my ex-husband was diagnosed with COVID-19 on June 26.
During this time, several areas became swollen and formed hard lumps.
The swollen areas initially included the joint between the thumb and palm, the neck under the ear, and on July 6, he developed swelling in the armpit.
He visited an orthopedic doctor on July 4, who suggested that the swelling might be due to lymphatic infection and prescribed dicloxacillin 250 mg/cap, L-Cysteine 20 mg, and diclofenac potassium 25 mg/tab, but the swelling did not subside and he continued to experience pain.
On July 7, during a follow-up visit, the orthopedic doctor stated it was cellulitis and recommended hospitalization for surgery, but advised him to wait at home for a bed.
On July 8, he consulted another physician who suggested it might be caused by the coronavirus, or possibly Kikuchi-Fujimoto disease, and mentioned the worst-case scenario could be lymphoma, scheduling a biopsy for July 12.
In the meantime, blood tests showed elevated white blood cell and lymphocyte counts, and starting July 7, he began experiencing swelling from the right forearm to the elbow.
Now, my ex-husband is unsure which specialist to follow, whether to proceed with surgery or to have the biopsy first.
Therefore, I would like to seek your advice.
Thank you for taking the time to read this, and I hope you can provide guidance on the next steps.
Wishing you all the best in your work, thank you.

Muzi, 20~29 year old female. Ask Date: 2022/07/09

Dr. Hong Yuanbin reply Internal Medicine

Hello, based on your description, the main issue is the enlargement of the lymph nodes.
One aspect that needs clarification is whether this lymphadenopathy occurred suddenly after a COVID-19 infection or if it has been present for some time.
If it occurred suddenly, theoretically, it should be gradually subsiding now.
If it is indeed subsiding, this may indicate an acute infection, such as COVID-19 or cellulitis, which should improve with the use of these medications.
However, if it has been present for a while and is now increasing in size, we need to be cautious about potential lymphatic system issues.
If there has been no gradual resolution, a biopsy should definitely be considered.
Thank you for your question.

Reply Date: 2022/07/09

More Info

Navigating conflicting medical opinions can be quite challenging, especially when it comes to conditions like lymphadenopathy and cellulitis. Based on the information provided, your ex-husband's situation involves several key factors that need to be considered in order to arrive at a clearer understanding of his condition and the appropriate course of action.

Understanding Lymphadenopathy and Cellulitis
Lymphadenopathy refers to the enlargement of lymph nodes, which can occur due to various reasons, including infections (viral or bacterial), autoimmune diseases, or malignancies. In this case, the swelling in the neck and armpit areas could indicate a response to an infection, possibly related to his recent COVID-19 diagnosis.
Cellulitis, on the other hand, is a bacterial skin infection that can cause redness, swelling, and pain in the affected area. It typically occurs when bacteria enter through a break in the skin. The fact that your ex-husband has hard lumps and swelling could suggest either lymphadenopathy due to an infection or cellulitis, especially if there are signs of skin involvement.

Conflicting Medical Opinions
1. Initial Diagnosis: The orthopedic physician's initial assessment of lymphatic infection aligns with the presence of swollen lymph nodes. The prescribed antibiotics (dicloxacillin) were appropriate for treating bacterial infections, but the lack of improvement suggests that the infection may not be responding to the treatment or that it is not bacterial in nature.

2. Subsequent Opinions: The suggestion of cellulitis and the need for hospitalization indicates a concern for a more serious infection that might require intravenous antibiotics or surgical intervention. The mention of Kikuchi-Fujimoto disease, which is a rare condition that can cause lymphadenopathy, adds another layer of complexity. This condition is often self-limiting and associated with viral infections, but it can mimic more serious conditions.

3. Concerns for Lymphoma: The mention of lymphoma is understandably alarming. While lymphadenopathy can be associated with malignancies, it is essential to consider the entire clinical picture, including the patient's history, symptoms, and laboratory findings.

Recommended Course of Action
Given the conflicting opinions and the seriousness of the symptoms, the following steps are advisable:
1. Consult a Specialist: It may be beneficial to consult a hematologist or an infectious disease specialist. They can provide a more focused evaluation of the lymphadenopathy and any potential underlying causes.

2. Follow-Up Imaging and Biopsy: Since a biopsy has been scheduled, it is crucial to proceed with this step. A biopsy can provide definitive information about the nature of the lymph nodes and help rule out malignancies or confirm infections.

3. Monitor Symptoms: Keep a close watch on any changes in symptoms, such as increased swelling, pain, fever, or new symptoms. If there is a rapid deterioration, seek immediate medical attention.

4. Avoid Delay in Treatment: If cellulitis is suspected and there are signs of systemic infection (like fever or spreading redness), it is essential to address this promptly. If hospitalization is recommended, it should not be delayed, as untreated cellulitis can lead to serious complications.

5. Consider a Multidisciplinary Approach: Given the complexity of the case, a team approach involving different specialists may provide the best outcome. This could include an orthopedic surgeon, an infectious disease specialist, and a hematologist.

Conclusion
In conclusion, your ex-husband's situation requires careful evaluation and possibly a combination of treatments based on the results of the biopsy and further imaging. It is essential to communicate openly with the healthcare providers, ask questions, and ensure that all concerns are addressed. The goal is to arrive at a diagnosis that accurately reflects the underlying condition and to initiate the most effective treatment plan.

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