ANSWER 35
Transient small nodes in the neck or groin are common benign findings. However, a 3%4cm
mass of nodes for 2 months is undoubtedly abnormal. Persistent lymphadenopathy and con-
stitutional symptoms suggest a likely diagnosis of lymphoma or chronic leukaemia.
Sarcoidosis and tuberculosis are possible but less likely diagnoses. Lymph nodes are normally
barely palpable, if at all. The character of enlarged lymph nodes is very important. In acute
infections the nodes are tender and the overlying skin may be red. Carcinomatous nodes are
usually very hard, fixed and irregular. The nodes of chronic leukaemias and lymphomas are
non-tender, firm and rubbery. The distribution of enlarged lymph nodes may be diagnostic.
Repeated minor trauma and infection may cause enlargement of the locally draining lymph
nodes. Enlargement of the left supraclavicular nodes may be due to metastatic spread from
bronchial and nasopharyngeal carcinomas or from gastric carcinomas (Virchow’s node).
However, when there is generalized lymphadenopathy with or without splenomegaly, a sys-
temic illness is most likely. The typical systemic symptoms of lymphoma are malaise, fever,
night sweats, pruritus, weight loss, anorexia and fatigue. Fever indicates extensive disease,
and may be associated with night sweats. Severe skin itching is a feature of some cases of
lymphoma and other myeloproliferative illnesses.
The incidence of lymphoma is greatly increased in patients who are immunosuppressed,
such as organ transplant recipients and patients with HIV infection.
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- Infections: infectious mononucleosis or ‘glandular fever’ (caused by Epstein–Barr
virus infection), toxoplasmosis, cytomegalovirus infection, acute HIV infection,
tuberculosis, brucellosis and syphilis. - Inflammatory conditions: systemic lupus erythematosus, rheumatoid arthritis and
sarcoidosis. - Lymphomas or chronic lymphocytic leukaemia.
Major differential diagnosis of generalized lymphadenopathyThe most likely clinical diagnosis in this man is lymphoma. The patient should be referred to
a local haemato-oncology unit. He should have a lymph-node biopsy to reach a histological
diagnosis, and a computed tomography (CT) scan of the thorax, abdomen and bone marrow
to stage the disease. CT scanning is a non-invasive and effective method of imaging retroperi-
toneal, iliac and mesenteric nodes. Positron-emission tomography (PET) combined with CT
increases the sensitivity for detecting disease (Fig. 35.1), and is useful for assessing response
to treatment. The patient will require treatment with radiotherapy and chemotherapy.
Radiotherapy alone is reserved for patients with limited disease, but this patient has wide-
spread disease. He should be given allopurinol prior to starting chemotherapy, to prevent
massive release of uric acid as a consequence of tumour lysis, which can cause acute renal
failure.