PA19.1-6 | Approach to Lymphadenopathy — Summary & Reflection

REFLECT

You've now built a structured framework for lymphadenopathy. Pause and test your thinking:

1. A 14-year-old girl has bilateral cervical lymphadenopathy after a cold. Which feature would make you stop watching and start investigating?
2. Why does the consistency of rubbery point to lymphoma more strongly than firm?
3. A FNAC report comes back as "reactive lymphoid tissue." Under what circumstances would you still proceed to excision biopsy?
4. Revisit the opening case: 22-year-old male, 6-week rubbery, non-tender posterior cervical node. What is your top differential, and what investigation will you request?

Discuss with a peer — there is no single right answer to question 3; it depends on the clinical context.

KEY TAKEAWAYS

Core take-home points — PA19.1:

• A lymph node has three compartments: cortex (B cells/follicles), paracortex (T cells), medulla (plasma cells + sinuses). Each compartment has a signature reactive pattern.

• Lymphadenopathy = node > 1 cm; pathological if persistent > 6 weeks or with alarming features.

• Causes are classified as: reactive/benign (infective + non-infective) | neoplastic (primary lymphoma + metastatic carcinoma) | miscellaneous (sarcoidosis, drug, autoimmune).

• Three reactive hyperplasia patterns: follicular (B-cell stimulation → RA, HIV, bacteria) | paracortical (T-cell stimulation → viruses, drugs) | sinus histiocytosis (macrophage expansion → draining carcinoma).

• Clinical discriminators: rubbery = lymphoma; hard/fixed = metastasis; tender/soft = acute infection; matted = TB.

• Site: left supraclavicular (Virchow's node) = GI/thoracic/pelvic primary.

• Investigation: FNAC for suspected TB or metastatic carcinoma; excision biopsy always for suspected lymphoma (architecture essential for subclassification).

• Age: < 14 → infective; 15–35 → EBV + lymphoma; > 50 → malignancy dominant.