T

THE PATIEwNoman CASE REPORT

52-year-old
INGS
EXAM FIND
man visit,
 t a well wo al signs
A
vit
the patient’s
a l exam were
and physic
Shannon Scott, DO,
n of
the exceptio
FACOFP; Benjamin Kitt,
normal, with inguinal lymph DO; Dominic Derenge,
left
3 enlarged
DO
ly
approximate
Arizona College of
nodes and l
Osteopathic Medicine,
right inguina Midwestern University,
5 enlarged Glendale
s.
lymph node
sscott1@midwestern.
edu

The authors reported no

THE CASE potential conflict of interest

relevant to this article.
A 52-year-old woman presented to our family clinic for a well woman exam. The only com-
plaints she had were fatigue, which she attributed to a work day that began at 4 am, and
hot flashes. She denied fever, weight loss, abdominal pain, medication use, or recent foreign
travel. She had a history of hyperlipidemia and surgical removal of a cutaneous melanoma
at age 12.
Her vital signs and physical exam were normal with the exception of 3 enlarged left
inguinal lymph nodes and approximately 5 enlarged right inguinal lymph nodes. The nodes
were freely moveable and non-tender. No additional lymphadenopathy or splenomegaly was
found.

THE DIAGNOSIS
The patient’s work-up included a Pap smear, complete blood count (CBC), comprehensive
metabolic panel (CMP), and pelvic and inguinal ultrasound. All tests were normal, except
the ultrasound, which revealed 3 solid left inguinal lymph nodes measuring 1.2 to 1.6 cm
and 6 solid right inguinal lymph nodes measuring 1.1 to 1.8 cm. An abdominal and pelvic
computed tomography (CT) scan with contrast identified nonspecific mesenteric, inguinal,
retrocrural, and retroperitoneal adenopathy. An open biopsy of the largest inguinal lymph
node revealed follicular lymphoma, a form of non-Hodgkin’s lymphoma. (Hodgkin’s and
non-Hodgkin’s lymphoma (NHL) are uncommon causes of inguinal lymphadenopathy.1)
We consulted Oncology and they recommended a positron emission tomography
(PET)/CT scan, which showed widespread lymphadenopathy. A bone marrow biopsy con-
firmed follicular lymphoma grade II, Ann Arbor stage III.

DISCUSSION
Generalized lymphadenopathy involves lymph node enlargement in more than one region
of the body. Lymph nodes >1 cm in adults are considered abnormal and the differential
diagnosis is broad (TABLE2-5). A patient’s age is a significant factor in the evaluation of pe-
ripheral lymphadenopathy.2-5 Results from one study of 628 patients who underwent nodal
biopsy for peripheral lymphadenopathy revealed approximately 80% of nodes in patients
under age 30 were noncancerous and likely had an infectious cause.3 However, among pa-
tients over age 50, only 40% were noncancerous.3
Node enlargement can be palpated in the head, neck, axilla, inguinal, and popliteal ar-
eas. Inguinal lymph nodes up to 2 cm in size may be palpable in healthy patients who spend
time barefoot outdoors, have chronic leg trauma or infections, or have sexually transmitted
infections.6 However, any lymph node >1 cm in adults should be considered abnormal.2-5
C ON TIN U ED

JFPONLINE.COM VOL 65, NO 3 | MARCH 2016 | THE JOURNAL OF FAMILY PRACTICE 195
CASE REPORT

TABLE

Adult peripheral lymphadenopathy: The differential is broad2-5

Malignancies Infections Autoimmune disorders Miscellaneous

• Kaposi’s sarcoma • Brucellosis • Dermatomyositis • Amyloidosis

• Leukemias • Coccidioidomycosis • Rheumatoid arthritis • Miscellaneous (autotoxins,
antivenoms, streptokinase,
• Lymphoma • Cytomegalovirus • Sjögren’s syndrome
vaccines)
• Metastases • Human immunodeficiency • Systemic lupus
• Sarcoidosis
virus erythematosus
• Skin cancer
• Serum sickness medications
• Infectious mononucleosis
(such as allopurinol, atenolol,
• Lyme disease barbiturates, captopril,
carbamazepine, cephalosporins,
• Lymphogranuloma venereum
fluoxetine, gold injections,
• Mycobacterial infection griseofulvin, hydralazine,
penicillin, phenytoin, primidone,
• Syphilis
pyrimethamine, quinidine,
• Toxoplasmosis sulfonamides, sulindac)
• Tuberculosis
• Tularemia
• Typhoid fever
• Viral hepatitis

Method of diagnosis stein-Barr virus, or medications should be

depends on malignancy risk treated appropriately. With no cause identi-
A definitive diagnosis in patients with lymph fied, 4 weeks of observation is recommended
nodes >1 cm can be made by open lymph before biopsy.2,4,5,8 CT, PET, and biopsy should
node biopsy (the gold standard) or fine nee- be considered early for large, concerning
dle aspiration (FNA); however, these proce- masses. No evidence supports empiric anti-
dures are rarely needed if malignancy risk is biotic use for unknown causes.2,5
low. z High risk for malignancy is suggested
Data on the prevalence of malignant pe- in patients who are ≥50 years, present with
ripheral lymphadenopathy is limited.4 Fijten constitutional symptoms, have lymphade-
et al reported that among 2556 patients who nopathy >1 cm in >2 regions of the body, his-
presented to a family medicine clinic with tory of cancer, or have nodes that are rapidly
unexplained lymphadenopathy, the preva- enlarging, firm, fixed, or painless.2,3,5,7,9 Supra-
lence of malignancy was as low as 1.1%.7 clavicular lymphadenopathy has the highest
However, the prevalence of malignant lymph risk for malignancy, especially in patients
nodes among patients referred to a surgical ≥40 years.7 Enlarged iliac, popliteal, epitroch-
center for biopsy by primary care physicians lear, and umbilical lymph nodes are never
was approximately 40% to 60%.3 This high- normal.2,4,5,7,10 Biopsy should be considered
lights the importance of a thorough history, early in these patients.2-4,7 FNA or core needle
physical exam, and referral when appropriate biopsy is acceptable for an initial diagnosis,
to increase the yield of diagnostic biopsies. but negative results may require open bi-
z Low risk for malignancy is suggested opsy.1,5,8 Prior to biopsy, imaging with ultra-
when lymphadenopathy is present for less sound is recommended.1,2,8,11
than 2 weeks or persists for more than one z Our patient was offered rituximab
year with no increase in size.2 Benign causes alone or rituximab in addition to cyclophos-
such as sexually transmitted infections, Ep- phamide, hydroxydoxorubicin, vincristine,

196 THE JOURNAL OF FAM ILY PRACTICE | M A R C H 2016 | VOL 65, N O 3

and prednisone (R-CHOP). The patient chose distinguishing benign lymphadenopathy
rituximab alone, which resulted in a 30% re- (reactive lymphadenitis) from malignant
duction in the size of her intra-abdominal lymphadenopathy.
disease. At this point, the patient and her on- In patients with low risk for malignancy,
cologist chose to stop treatment and monitor a period of 4 weeks of observation is reason-
her clinically. able. Biopsy should be considered early for
Three months later, the patient returned risk factors including patient’s age ≥50, con-
to our family clinic complaining of postnasal stitutional symptoms, lymphadenopathy
drip, throat pain, and neck fullness that she’d >1 cm in >2 regions of the body, history of
had for one month that weren’t responsive to cancer, or rapidly enlarging nodes. JFP
over-the-counter remedies and antibiotics.
A supervised osteopathic medical student’s
exam revealed right tonsillar enlargement References
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THE TAKEAWAY Br J Cancer. 2003;88:354-361.
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