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Answer 4
  1. Cervical lymph node biopsy. The rapidly growing lymph node and fatigue suggests Richter’s transformation, the evolution of CLL to an aggressive lymphoma (most commonly diffuse large B-cell lymphoma). This phenomena occurs in up to 10% of patients with CLL.4 Lymph node biopsy would establish the diagnosis. The newly transformed lymphomas typically respond poorly to therapy, and most patients will die of their disease. The asymmetry of the lymphadenopathy and lack of pharyngitis makes strep throat and mononucleosis less likely. CT scans and laryngoscopy would be of little benefit.

    4. Robertson LE, Pugh W, O’Brien S, et al. Richter’s syndrome: a report on 39 patients. J Clin Oncol 1993;11:1985–9.

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