Audience

• Highland HSCP

Lymph node enlargement can occur in infective and neoplastic conditions. Neoplastic lymph nodes tend to be non-tender and progressive. In the case of lymphoma, lymphadenopathy may be associated with B symptoms (over 10% weight loss in 6 months, drenching sweats or unexplained fevers), alcohol-induced lymph node pain, itch or full blood count abnormalities. However frequently in lymphoma the blood count is normal so this should not necessarily reassure if other clinical concerns. Repeatedly waxing and waning lymphadenopathy does not necessarily exclude a diagnosis of lymphoma.

Causes

• Infections; particularly localised infection, tuberculosis, syphilis
• Lymphoma or other haematological malignancy
• Non-haematological malignancy g. Virchow’s node in left supraclavicular fossa from lung or gastrointestinal malignancy
• Sarcoidosis
• Skin conditions g. eczema
• Kikuchi disease

History and examination

To look at causes above. Ask about infections, itch, alcohol-induced pain, weight loss, sweats and fevers. A travel history may be informative. Systemic enquiry is required. Examination for splenomegaly and hepatomegaly as well as other lymph node areas. Ask about symptoms suggestive of superior vena cava obstruction or stridor.

Suggested investigations

• Full blood count and blood film (urgent)
• Inflammatory markers
• Renal and liver function
• Calcium
• LDH
• Immunoglobulins and serum protein electrophoresis
• HIV test
• Monospot test if possible EBV or syphilis, toxoplasma, CMV and EBV serology as appropriate
• Autoimmune screen in appropriate

Management

Please refer to the appropriate surgical department if:

• Lymphadenopathy for less than six weeks in association with: B symptoms, hepatomegaly or splenomegaly, rapid nodal enlargement, disseminated or generalised nodal enlargement, anaemia or thrombocytopenia, hypercalcaemia, itch.
• Lymphadenopathy over 1cm persisting for more than 6 weeks with no obvious infective precipitant.
• If there is concern that the patient may have a haematological malignancy and does not fall neatly into one box please discuss via Clinical Dialogue

In general ENT surgeons deal with neck lymph nodes, breast surgeons with axillary nodes and general surgeons with inguinal nodes. Referral to the appropriate surgical team will reduce delays and allow for other differentials to be appreciated (e.g. cervical lymph node enlargement not due to haematological malignancy). Please liaise via Clinical Dialogue if uncertainty.

If the lymphadenopathy is associated with a lymphocytosis please refer to haematology directly.

For some patients with mild lymphadenopathy and no concerning symptoms an ultrasound scan can be of value to assess size and appearances of the lymph node architecture which can often point towards the aetiology of the lymphadenopathy.