HNY Policy and Pathway Repository - North Yorkshire

Palpable lymph nodes are most commonly noted in the neck, axillae or groin. The most common cause will be inflamed lymph nodes in response to a local infection, however if no obvious inflammatory cause is present, or if nodes are persistent, then other causes should also be considered. Concerning features include unexplained fever, night sweats, shortness of breath, pruritus, weight loss or alcohol-induced lymph node pain.

None provided

Differential diagnosis:

• Infection: bacterial, viral, parasitic or fungal. Often tender. Can be acute or chronic e.g. tuberculosis, HIV.
• Local skin disease
• Haematological malignancy, esp. lymphoma or leukaemia
• Metastatic solid tumour e.g. Virchows node in left supraclavicular fossa from lung or gastrointestinal malignancy
• Others: collagen disorder (SLE, RA), sarcoidosis, Kikushi disease and other rarer causes.

Investigation:

• FBC (urgent <48 hours), blood film and inflammatory markers.
• Viral serology, if appropriate (e.g. EBV, CMV, toxoplasma, HIV)
• NICE guidelines also recommend as urgent chest x-ray with persistent cervical or supraclavicular lymphadenopathy.

Examination:

• Look for local cause, e.g. infection, skin disorder.
• Examine for cervical, supraclavicular, axillary and inguinal lymph nodes.
• Palpate abdomen for hepatomegaly or splenomegaly.

Referral:

• Features suggesting haematological malignancy may include drenching night sweats, fever, shortness of breath, weight loss (>10% within 6 months), cytopenias, generalised itch, alcohol-induced nodal pain (rare but associated with Hodgkin lymphoma) or hepato-splenomegaly.
• Neck lumps should initially be referred to ENT for assessment +/- biopsy
• If suspicion of haematological malignancy then should be referred (2WW) to Haematology (or ENT if neck lump).
• If there is a peripheral blood lymphocytosis then flow cytometry of peripheral blood lymphocytes may give a diagnosis without need for a biopsy (see separate protocol for investigation of lymphocytosis).

Haematology Handbook - South Tees Hospitals NHS Foundation Trust
 

References:

NICE. Suspected cancer: recognition and referral. June 2015, update Oct 2023.

NICE Clinical Knowledge Summary. Neck lump (October 2020) https://cks.nice.org.uk/neck-lump 

NICE Clinical Knowledge Summary. Haematological Cancers - Recognition and Referral (February 2021). https://cks.nice.org.uk/haematological-cancers-recognition-and-referral 

• South Tees Hospitals