The patient
A 64 year old lady attended with two problems. First, she wanted to know if she was too old to go back on her HRT which she hadn't taken for well over 10 years. And, before we had a chance to explore that question, she had moved onto problem number two – a swelling in her neck which she'd noticed for a month or two.
It seemed to be getting bigger and was very slightly uncomfortable. She volunteered no other particular symptoms and denied any recent sore throat, upper respiratory symptoms or dental trouble.
Her past medical history was unremarkable apart from hypothyroidism - for which she took levothyroxine 75mcg per day - and she had never smoked.
First instinct
Examination confirmed my impression that this was an enlarged cervical gland, which seemed non tender to palpation. The question, of course, was what was the underlying cause? In such cases, the hope is, of course, that there's a benign and simple explanation, such as a local infection. But a careful examination of the region revealed no infective focus. No other nodes were palpable and abdominal examination revealed no hepatosplenomegaly.
Differential diagnosis
- Infection (acute, such as URTI, or chronic, such as TB)
- Nasopharyngeal malignancy
- Sarcoidosis
- Collagen vascular disease
- Chronic lymphocytic leukaemia
- Lymphoma
A local, acute infection was looking unlikely – though the possibility of a more obscure and chronic infection, such as TB, remained.
Nasopharyngal malignancy was certainly a front-runner. The absence of other symptoms was of no reassurance, as such malignancies often present with local spread – though the fact that she had never smoked did offer some reassurance.
Sarcoidosis can present with localised lymphadenopathy, but usually affects a younger age group. A collagen vascular disease is another cause of enlarged lymph nodes but there was no associated skin rash or arthropathy.
Which left serious haematological disorders as a distinct possibility. These include Chronic Lymphocytic Leukaemia (CLL) and lymphomas. This patient was certainly in the right age group for CLL, but the absence of an enlarged liver or spleen was reassuring – 50% of these patients have hepatosplenomegaly. Non-Hodgkin's lymphoma usually affects multiple nodes – so Hodgkin's seemed more likely. This has a bimodal incidence, with the second peak affecting patients over the age of 50.
The hidden clue
Perhaps not appreciating the potential gravity of her swollen gland, she reverted to her other agenda – consideration of HRT. Why? Because she had been sweating profusely at night in the weeks leading up to her attendance.
Getting on the right track
Night sweats, of course, pointed towards a lymphoma – with TB perhaps a lesser possibility. By this point, it was clear that a biopsy was going to be needed, and urgently, so she was referred to the ear, nose and throat department under the two week rule. A full blood count in the interim showed a slight normochromic, normocytic anaemia and a mildly elevated ESR – which did nothing to narrow the differential but did confirm the clinical impression that she was suffering significant pathology. The biopsy revealed Hodgkin's lymphoma, and she was transferred to the care of the haematologists for further management.
Dr Keith Hopcroft is a GP in Laindon, Essex
What's causing the swelling on this woman's neck? What's causing the swelling on this woman's neck?
