Axial STIR and T1, coronal T2, and sagittal T1 images of the neck are included.  To make it easier, only one question for this case:

1.  List 5 differential diagnoses for the salient finding.

In order to list an appropriate differential the most important thing is to make the correct finding.  In this case the patient has multiple enlarged cervical lymph nodes as highlighted in a select few images on the right.  Often the threshold between a normal vs abnormal lymph node is a size greater than 1 cm.
​
Most cases of lymphadenopathy can be described by two broad categories:
1.  Reactive/inflammatory - in response to an inflammatory process including:
  • bacterial infectious disease - eg. Tubercolosis
  •  viral infectious disease (immunodeficiency syndrome, cytomegalovirus (CMV), Epstein Barr, herpes simplex, measles) 
  •  autoimmune disorder - Systemic lupus erythematosus (SLE), sarcoidosis, rheumatoid arthritis (RA)
  •  Multiple sclerosis - cervical lymphadenopathy has been seen in patients, role still unclear
  • Castleman disease - tumor-like process thought to be due to a low grade inflammatory process but may be associated with malignancy in the body (eg Kaposi's sarcoma)


2.  Malignant:
  • metastasis
  • lymphoma/leukemia
  • other local malignancy


Lymphadenopathy may also occur from various medications.  This list would include such things as penicillin, quinidine, sulfonimids, cephalosporins, phenytoin (Dilantin), carbamazepine (Tegretol), quinidine, among others. 

Often, a good history and clinical examination can provide the clue to the correct diagnosis of lymphadenopathy.  In some cases further evaluation may be required to identify the cause.  This may include blood tests and lymph node or bone marrow aspiration and biopsy.  Doppler ultrasound assessing vascularity of the nodes has been found to be useful in  distinguishing between benign and malignant lymphadenopathy (Differential diagnosis of cervical lymphadenopathy: usefulness of color Doppler sonography. D G Na, H K Lim, H S Byun, H D Kim, Y H Ko, and J H Baek American Journal of Roentgenology 1997 168:5, 1311-1316)

Treatment of lymphadenopathy is based on the underlying etiology.  ​

Case Diagnosis:  Chronic Lymphocytic Leukemia (CLL)

In the case presented here, the patient was diagnosed with .  CLL is the most common form of adult non-Hodgkin's lymphoma and typically occurs in older (over 65) population.

Clinical presentation of CLL can include lymphadenopathy which may be painless, enlargement of the liver and/or spleen (hepatomegaly, splenomegaly), recurrent infections, anemia and thrombocytopenia.  Unintentional weight loss, fever, night sweats may also be present.  However, very frequently CLL may not present with any specific symptoms and be identified on blood work or other testing such as imaging performed for other reasons.  

CLL treatment options include a "watch and wait" approach if asymptomatic.  CLL can be slowly progressive and some patient's may remain relatively asymptomatic with no apparent shortening of life expectancy.  Chemotherapy is main treatment option, especially if the patient starts losing weight, develops a fever, has severe fatigue, or night sweats unattributable to an infection, or follow up laboratory testing shows progressive anemia and thrombocytopenia.  Immunotherapy and targeted drug therapy options are also available.  Radiation therapy and surgery are less commonly needed.