SN7 SHORT NOTE 5M

Write a short note on generalised lymphadenopathy — causes, clinical evaluation and investigations.

General Medicine · Final Professional

Definition

Lymphadenopathy means nodes that are abnormal in size, consistency or number. A node is generally considered enlarged if > 1 cm (> 1.5 cm for inguinal, > 0.5 cm for epitrochlear). Generalised lymphadenopathy is enlargement of nodes in two or more non-contiguous regions, and always implies a systemic process, in contrast to localised lymphadenopathy which usually reflects drainage from a local lesion.

Causes

Infective

Viral: EBV (infectious mononucleosis), CMV, HIV (persistent generalised lymphadenopathy), rubella, measles, dengue, hepatitis B.
Bacterial: tuberculosis, brucellosis, secondary syphilis, typhoid, leptospirosis.
Protozoal/fungal: toxoplasmosis, kala-azar, histoplasmosis.

Malignant

Lymphoma — Hodgkin's (contiguous spread, Reed–Sternberg cells, alcohol-induced node pain) and non-Hodgkin's (non-contiguous, extranodal involvement).
Leukaemia — especially chronic lymphocytic leukaemia and acute lymphoblastic leukaemia.
Metastatic carcinoma (usually localised, but may be widespread late).

Autoimmune / inflammatory: SLE, rheumatoid arthritis (Felty's syndrome), adult-onset Still's disease, sarcoidosis, Sjögren's syndrome, dermatomyositis.

Drugs: phenytoin (pseudolymphoma), carbamazepine, allopurinol, hydralazine, sulphonamides.

Others: amyloidosis, Castleman's disease, Kikuchi's disease, storage disorders (Gaucher's, Niemann–Pick), hyperthyroidism.

CLINICAL PEARL

The mnemonic for generalised lymphadenopathy causes is "HIV, TB, lymphoma, SLE, drugs" — cover these five in every answer. In India, tuberculosis and HIV together account for the majority of cases.

Clinical Evaluation

History:

duration and rate of growth
fever, night sweats, weight loss (B symptoms)
sore throat
pruritus
sexual history and risk factors for HIV
contact with TB
animal and travel exposure
drug intake
occupational exposure.

Examination — features that discriminate:

Feature	Benign / Reactive	Malignant
Consistency	Soft, tender	Hard, rubbery (lymphoma), stony hard (carcinoma)
Mobility	Mobile	Matted, fixed to skin or deep structures
Tenderness	Usually tender	Usually painless
Growth	Rapid then regressing	Progressive, relentless
Size	Usually < 2 cm	> 2 cm and enlarging
Site	Any	Supraclavicular (Virchow's node) is malignant until proved otherwise

Also examine the liver and spleen, Waldeyer's ring, skin (rash of SLE, dermatitis), and look for pallor and petechiae suggesting marrow involvement.

Investigations

CBC with peripheral smear — atypical lymphocytes (EBV), lymphocytosis with smudge cells (CLL), blasts (acute leukaemia), pancytopenia (marrow infiltration).
ESR, CRP, LDH — LDH is a prognostic marker in lymphoma.
Serology: monospot/EBV, HIV ELISA, VDRL, toxoplasma, CMV.
Mantoux/IGRA, sputum for AFB, CBNAAT if TB suspected.
Chest X-ray for hilar and mediastinal nodes (lymphoma, TB, sarcoidosis); CECT neck/chest/abdomen/pelvis for staging.
ANA and anti-dsDNA if connective tissue disease suspected; serum ACE in sarcoidosis.
Excisional lymph node biopsy — the definitive investigation. Choose the largest, most abnormal node, preferably supraclavicular or cervical; avoid inguinal nodes, which frequently show non-specific reactive change.
Bone marrow aspiration and biopsy for staging and for marrow infiltration.
PET-CT for lymphoma staging and response assessment.

EXAM TIP

FNAC is inadequate for diagnosing lymphoma because nodal architecture is essential for classification. FNAC is acceptable for suspected tuberculosis (with AFB stain and CBNAAT on the aspirate) or metastatic carcinoma. Always write excisional biopsy for lymphoma.

All questions in Miscellaneous

Every General Medicine chapter →