CASE 35: SWELLING IN THE NECK
History
A 38-year-old man presents to his general practitioner (GP) complaining of a painless
lump on the right side of his neck. This has been present for about 2 months and seems to
be enlarging. He has had no recent throat infections. He has been feeling generally unwell
and has lost about 5 kg in weight. The patient has also developed drenching night sweats.
Simultaneously he has noticed severe generalized itching. He has had no significant past
medical history. He is an accountant, and married with three children. He neither smokes
nor drinks alcohol and is not taking any regular medication.
Examination
His temperature is 37.8°C. There is a smooth, firm 3%4cm palpable mass in the right supra-
clavicularfossa. There are also lymph nodes 1–2 cm in diameter, palpable in both axillae
and inguinal areas. His oropharynx appears normal. There are multiple excoriations of his
skin. His pulse rate is 100/min regular and blood pressure 112/66 mmHg. Examination of
his cardiovascular and respiratory systems is normal. On abdominal examination, there is
a mass palpable 3 cm below the left costal margin. The mass is dull to percussion and it is
impossible to palpate its upper edge. Neurological examination is normal.
NormalHaemoglobin 11.6 g/dL 13.3–17.7 g/dL
Mean corpuscular volume (MCV) 87 fL 80–99 fL
White cell count 12.2% 109 /L 3.9–10.6% 109 /L
Platelets 321 % 109 /L 150–440% 109 /L
Erythrocyte sedimentation rate 74 mm/h !10 mm/h
Sodium 138 mmol/L 135–145 mmol/L
Potassium 4.2 mmol/L 3.5–5.0 mmol/L
Urea 5.2 mmol/L 2.5–6.7 mmol/L
Creatinine 114 &mol/L 70–120&mol/L
Calcium 2.44 mmol/L 2.12–2.65 mmol/L
Phosphate 1.1 mmol/L 0.8–1.45 mmol/L
Total protein 65 g/L 60–80 g/L
Albumin 41 g/L 35–50 g/L
Bilirubin 16 mmol/L 3–17 mmol/L
Alanine transaminase 22 IU/L 5–35 IU/L
Alkaline phosphatase 228 IU/L 30–300 IU/LUrinalysis: no protein; no bloodINVESTIGATIONS
Questions
- What is the likely diagnosis?
- How would you investigate and manage this patient?