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Clinical Problem Solving: Pathology |

Pathology Quiz Case 2

Paul E. Johnson, MD; David E. Rosow, MD; Govind Bhagat, MD; Ian S. Storper, MD
Arch Otolaryngol Head Neck Surg. 2009;135(3):320-324. doi:10.1001/archoto.2008.548-a.
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A 53-year-old woman with presumed Sjögren syndrome and a 7-year history of symmetrical, bilateral submandibular gland swelling presented with progressive, asymmetrical enlargement of the left submandibular gland. Given her prior diagnosis of Sjögren syndrome, there was concern regarding non-Hodgkin lymphoma. A review of systems revealed fatigue, keratoconjunctivitis, and xerostomia. The patient denied fever, chills, night sweats, and weight loss as well as any history of smoking or alcohol use. A recent tuberculin test was negative for purified protein derivative. The patient's medical history was remarkable for hypothyroidism and sequelae due to her autoimmune disease, including interstitial lung disease and interstitial nephritis. Her physical examination revealed symmetrically enlarged lacrimal glands and asymmetrical left submandibular gland enlargement. Magnetic resonance images of her face and neck were notable for bilaterally enlarged lacrimal glands and bilateral submandibular gland enlargement, more on the left than the right. The left gland measured 2.8 cm in greatest dimension, without a discrete mass. An axial T1-weighted, gadolinium-enhanced magnetic resonance image with fat saturation protocol is shown in Figure 1. Fine-needle aspiration of both submandibular glands revealed varying amounts of polymorphic, chronic inflammatory cell infiltrates.

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