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Lymphadenopathy and splenomegaly

Clinical Discipline(s)/Organ System(s)
Haematology, Immunology, General Practice, Anatomical Pathology, Ethics
Progress Test Topic(s)
Blood and lymph
A 60 year old man presented to his GP for a repeat prescription of his usual medications. On examination, he was found to have palpable lymph nodes (up to 2cm in size) in his cervical, axillary and inguinal regions. The spleen was palpable 4cm below the costal margin. On further questioning, he told his GP that he first noticed some lymph nodes in his neck about 6 months ago, but they had not changed in size or troubled him. He felt well in himself. A full blood count showed a lymphocytosis of 15 x 109/L and the presence of smear cells.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Anatomy and function of the lymphatic system, including the spleen and thymus
   - Development and role of T and B lymphocytes; describe humoral and cell-mediated immune responses
   - Peripheral blood abnormalities in chronic lymphocytic leukaemia (CLL)
   - Histopathology of Hodgkin and non-Hodgkin lymphomas
   - Genetic abnormalities in lymphoproliferative disorders and their roles in tumour growth
   - Science of flow cytometry
   - Distinction between monoclonal and polyclonal populations of lymphocytes
   - Pharmacology of chemotherapy for lymphoproliferative disorders (e.g. fludarabine, cyclophosphamide)
   - Mechanism of action of targeted immunotherapy (e.g. rituximab)
Clinical and Communication Skills 
   - History from a patient with lymphadenopathy and splenomegaly; assess symptoms that might differentiate infectious from neoplastic lymphoproliferative causes
   - Recognise ‘B symptoms
   - Examine the superficial lymph nodes and abdomen (particularly liver and spleen); document lymph node status, liver and spleen size for future comparison
   - Differential diagnosis of lymphadenopathy +/- splenomegaly, and splenomegaly alone
   - Interpret full blood count in a patient with CLL
   - Define monoclonal B cell lymphocytosis and explain its relationship to CLL
   - Indications for lymph node biopsy (fine needle aspirate [FNA], core biopsy and excisional biopsy), CT scanning, bone marrow biopsy
   - Outline staging systems for lymphoproliferative disorders
   - Describe the differences in presentation, management and prognosis between low grade and high grade lymphoproliferative disorders
   - Immunological complications of lymphoproliferative disorders: hypogammaglobuinaemia, immune-mediated haemolytic anaemia, immune thrombocytopenia (ITP)
   - Infectious complications of lymphoproliferative disorders and immunosuppression, including herpes zoster and infection with atypical organisms; management of herpes zoster
Personal and Professional Skills 
   - Equipoise and enrolling patients in research
   - Self-awareness about impact of discussing life changing news with a young patient and family/whānau
Hauora Māori 
   - Appropriate engagement and consultation with whānau
   - Consideration of patient and whānau needs with regards to ‘breaking bad news
   - Consideration of access to cultural/spiritual support for patient and whānau
Population Health 
   - Epidemiology of chronic lymphocytic leukaemia and lymphomas
   - Ethics of treatment, patient-informed choice and impact of quality of life
Conditions to be considered relating to this scenario
chronic lymphocytic leukaemia, lymphoma, infectious mononucleosis
Less common but 'important not to miss'
Waldenstrōm macroglobulinaema, hairy cell leukaemia, sarcoidosis, systemic lupus erythematosus (SLE), metastases, HIV, mycobacterial infection, vasculitis
Castleman’s Disease, amyloidosis
Related Scenarios
[Fever and adenopathy], [Neck lump]