🩺 Lymphadenopathy

Lymphadenopathy is the abnormal enlargement of lymph nodes, typically defined as a diameter greater than 1cm. It is a common clinical finding that usually represents a benign response to a localized or systemic infection. However, it can be the presenting feature of serious conditions including lymphoma, leukaemia, or metastatic solid tumours. The clinical challenge is to distinguish reactive nodes from those requiring urgent biopsy through careful assessment of 'B symptoms' and physical characteristics.

Determine the duration and rate of growth. Ask about 'B symptoms' (unexplained fever >38°C, drenching night sweats, or >10% weight loss in 6 months) which strongly suggest lymphoma. Inquire about localized symptoms (sore throat, skin infection, breast lumps). Explore risk factors: smoking (head and neck cancers), travel (TB/malaria), sexual history (HIV/syphilis), and animal scratches (cat-scratch disease). Check for a history of night sweats or pruritus.

Systematically palpate all node stations: submental, submandibular, cervical, supraclavicular, axillary, and inguinal. Note the size, consistency, mobility, and tenderness. Examine the 'upstream' drainage area for signs of infection or primary tumours (e.g., the scalp for cervical nodes, the breast for axillary nodes). Perform a full abdominal exam to check for hepatosplenomegaly, which might suggest a haematological malignancy. Look for systemic signs like rashes or joint swelling.

Reactive Lymphadenopathy (viral/bacterial), Lymphoma (Hodgkin/Non-Hodgkin), Metastatic Malignancy, Infectious Mononucleosis (EBV), Tuberculosis, HIV Infection, and Sarcoidosis.

Supraclavicular lymphadenopathy, 'B symptoms' (weight loss, night sweats, fever), hard/fixed nodes, size >2cm, and persistent nodes (>6 weeks).

Initial bloods include FBC with a blood film (leukaemia/lymphoma), ESR/CRP (inflammation), and LDH. Serology for EBV (Glandular fever), HIV, and Toxoplasmosis may be appropriate. Imaging starts with an ultrasound of the affected area, but a Chest X-ray is useful to look for hilar lymphadenopathy. The 'gold standard' for diagnosis of a suspicious node is an excision biopsy rather than a Fine Needle Aspiration (FNA), as architecture is required for lymphoma subtyping.

'Hard, fixed, and non-tender' nodes are highly suspicious for malignancy, whereas 'soft, mobile, and tender' nodes usually suggest infection. Supraclavicular nodes (e.g., Virchow’s node) are never normal and always warrant urgent investigation for malignancy. Generalized lymphadenopathy (two or more non-contiguous areas) suggests systemic disease like HIV, lymphoma, or sarcoidosis. A node larger than 1cm that persists for more than 6 weeks requires a definitive diagnosis.

Know the 2-week wait (2WW) criteria for unexplained lymphadenopathy (e.g., >2cm or persistent/growing). Identify the significance of the supraclavicular station. Understand why excision biopsy is preferred over FNA in suspected lymphoma. Recognize the clinical picture of Glandular Fever (EBV).