Endgames Picture Quiz

A man with generalised lymphadenopathy

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7445 (Published 12 December 2014) Cite this as: BMJ 2014;349:g7445
  1. Rosalie Magro, higher specialist trainee in general medicine and rheumatology,
  2. Andrew Borg, consultant physician and rheumatologist
  1. 1Department of Medicine, Mater Dei Hospital, Tal-Qroqq, Msida, MSD 2090, Malta
  1. Correspondence to: R Magro rosaliemagro{at}gmail.com

A 75 year old man with Paget’s disease, hypercholesterolaemia, and hypertension presented with a three year history of multiple neck lumps, which had never been investigated and had increased in size over the past two months. He felt generally well and had no history of fever or weight loss. His appetite was normal and there was no change in bowel habit. Clinical examination showed no abnormalities and he had no shortness of breath, chest pain, lower limb oedema, joint pains, or neurological symptoms.

On examination, he had hepatomegaly (width of three fingers) and his cervical, axillary, and inguinal lymph nodes were enlarged, hard, and non-tender bilaterally. His blood count, renal function, and C reactive protein (<57 nmol/L; reference range 0-95) were normal. He had a raised erythrocyte sedimentation rate (102 mm in the first hour (28-32) and altered liver function tests (alkaline phosphatase 6.5 µkat/L (0.67-2.15), alanine aminotransferase 0.35 µkat/L (0.08-0.68), γ-glutamyl transferase 9.67 µkat/L (0.13-1.02), and total bilirubin 29.5 µmol/L (1.72-17.1). Proteinuria (0.25 g/L) was noted on urinalysis. Chest radiography showed mediastinal lymphadenopathy. Computed tomography of the thorax, abdomen, and pelvis showed enlarged mediastinal, axillary, and inguinal lymph nodes, which varied in size from 1 cm to 3 cm, with eggshell calcifications and an enlarged liver with hypodense texture.

A lymph node biopsy was done and histological analysis performed (figure).

Fig 1 Section from a lymph node biopsy stained with Congo red and viewed under polarised light. Image courtesy of Ed Uthman, Houston, Texas, with permission1

Questions

  • 1. What are the causes of generalised lymphadenopathy?

  • 2. What does the histological section obtained by lymph node biopsy show?

  • 3. What further investigations are needed?

  • 4. How is the condition treated?

Answers

1. What are the causes of generalised lymphadenopathy?

Short answer

Generalised lymphadenopathy can be caused by infections (viruses, bacteria, fungi, or protozoans), cancer (including lymphoproliferative disorders), autoimmune disorders (including …

View Full Text

Sign in

Log in through your institution

Free trial

Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
Sign up for a free trial

Subscribe