Supposedly lymph nodes look like beans…. I’ll let you be the judge of that. Test yourself on this quiz on causes of lymphadenopathy!

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Approach to the patient with lymphadenopathy

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Question 1

Stem 1, question 1 of 4

Esther, 28 year old female, presents to GP with lumps in her neck and above her collarbones. She has been having intermittent fevers and night sweats for last 3 months, but puts this down to her menstrual cycle.
What is generalised lymphadenopathy?
Presence of palpable lymph nodes at three discrete locations
Presence of palpable lymph nodes in both superior and inferior to the umbilicus
Palpable lymph nodes in region involved according to the lymphatic drainage patterns
Presence of palpable lymph nodes in three or more chains
Enlargement of more than two contigous lymph nodes groups
Question 1 Explanation: 
Since we are considering causes of lymphadenopathy it is important to understand the two broad categories: generalised and localised. Generalised lymphadenopathy refers to the presence of palpable lymph nodes in three or more chains. Localised is associated with the region involved according to the lymphatic drainage patterns. The other answers are made up and false.
Question 2

Stem 1, question 2 of 4

Esther is presenting with B symptoms (constitutional symptoms)
Which of the following are B symptoms? Select all that apply  
Night sweats
Weight loss
Question 2 Explanation: 
B symptoms refer to the Ann Arbor staging of lymphomas where the presence or absence of these symptoms influence prognosis. The presence of B symptoms indicate systemic and more advanced disease rather than local. B symptoms are systemic features of fever, night sweats and weight loss. Pruritus and fatigue are not listed as B symptoms but can be present in an individual with lymphoma
Question 3

Stem 1, question 3 of 4

The GP suspects Esther has Lymphoma and arranges further investigations
What are the histological features of Hodgkin's lymphoma?
Non-caseating granulomas
Reed-Sternberg cells
Abnormal B and/or T cells
Absolute lymphocytosis
Multinucleated giant cells
Question 3 Explanation: 
Lymphoma is a heterogenous group of malignancies of the lymphoid system and can be very difficult to differentiate between Hodgkin's and Non-Hodgkin's lymphomas clinically and so biopsies are often required to make a diagnosis. Hodgkin's lymphoma arises from mature B cells and has two key histological findings: Reed-Sternberg cells and Hodgkin's cells. The other answer options refer to the following conditions respectively: Sarcoidosis, Non-Hodgkins, leukaemia and sarcoidosis.
Question 4

Stem 1, question 4 of 4

A diagnosis of Hodgkin's lymphoma is confirmed and Esther is started on treatment
What is the mechanism of action of doxorubicin?
DNA crosslinking
Inhibition of microtubule assembly in mitotic spindle
Inhibition of dihydrofolate reductase and DNA synthesis
Targeting of cells overexpressing Human Epidermal Growth Factor Receptor-2 (HER2) for tumour reduction & destruction
DNA intercalation and inhibition of RNA and DNA synthesis
Question 4 Explanation: 
Doxorubicin is an anthracycline antibiotic and can be used to treat Hodgkin's lymphoma, exerting it's mechanism through DNA intercalation and inhibition of RNA and DNA synthesis. The other answer options are the following classes of anti-neoplastic drugs respectively: alkylating agents, taxanes and vinca alkaloids, antifolates and trastuzumab (Herceptin)
Question 5

Stem 2, question 1 of 4

Eliza, a 45 year old female presents with lymphadenopathy, arthralgia, myalgia, morning stiffness and rash. She has no cough.
Which of the following is NOT a likely differential for this presentation?
Systemic Lupus Erythematosus
Rheumatoid arthritis
Sjogren's syndrome
Question 5 Explanation: 
Lymphadenopathy is not always just caused by cancers or infections! CHICAGO is a good method to remember causes of lymphadenopathy C- Cancer H- hypersensitivity syndromes I - infections C- collagen vascular disease A- atypical lymphoproliferative disorders G- granulomatous disease O - other causes Lymphadenopathy in the presence of arthralgias, myalgias, morning stiffness or rash should raise a concern for the presence of an underlying collagen vascular. Sarcoidosis is a chronic granulomatous disorder affecting the lungs, skin and eyes, although can mimic a number of features, the absence of a cough makes this differential less likely.
Question 6

Stem 2, question 2 of 4

3 years later Eliza returns with her 15 year old son, Nick. Nick has extreme fatigue, fever, lymphadenopathy and pharyngitis
What is the causative organism of Nick's presentation?
Human Immunodeficiency Virus
Toxoplasma gondii
Epstein Barr Virus
Hepatits B virus
Question 6 Explanation: 
Nick is presenting with the triad of fever, pharyngitis and lymphadenopathy of glandular fever which is caused by Epstein Barr virus. Cytomegalovirus, HIV, toxoplasmosis and hepatitis B can all cause lymphadenopathy but will not cause the key triad of symptoms that Nick is showing.
Question 7

Stem 2, question 3 of 4

Nick is a keen sportsman and is captain of the rugby team at school
Why should Nick avoid contact sport for at least 3-4 weeks?
Risk of transmission of disease during contact
Strenuous activity with glandular fever may result in a rash
Potential for hepatic rupture
Potential for splenic rupture
Possibility of Reye's syndrome
Question 7 Explanation: 
Splenomegaly can occur with glandular fever, which increases the risk of splenic rupture especially when coupled with contact sport. BMJ Best Practice (2021) recommends refraining from contact sports for at least 4 weeks, up to 8 weeks in some individuals. A rash may occur if penicillin is given with concurrent glandular fever. Reye's syndrome occurs when children are given aspirin so it should not ve given. Hepatitis can occur but the risk of rupture is not as significant as the spleen. Epstein Barr virus is spread through saliva not contact.
Question 8

Stem 2, question 4 of 4

The GP requests some blood tests for Nick
Which of the following is the most likely result?
Negative heterophile antibodies
Elevated urea
Low CD4+ count
High Lactate dehydrogenase
Question 8 Explanation: 
Lymphocytosis is seen in 70% of cases. Heterophile antibodies are a non-specific test for Epstein Barr virus so are likely to be positive. Elevated urea is seen in sarcoidosis. Low CD4+ counts are seen in HIV and AIDS. High Lactate dehydrogenase (LDH) is seen in Lymphoma.
Question 9
Andy presents to A&E with a hot and swollen right arm, he cut his forearm 4 days ago in the woods. Red, warm and tender streaks are visible on the skin of the upper limb. He also has tender axillary lymphadenopathy.
What is the most likely cause of the streaks on his arm?
Question 9 Explanation: 
Although many of these questions have focussed on generalised lymphadenopathy, it's important to remember localised lymphadenopathy is key too! This stem is pointing to an infection of the upper arm from the wound that has resulted in lymphangitis (inflammation of the lymphatic vessels with tender, enlarged lymph nodes). The axillary lymph nodes receive lymph from the upper arm hence are swollen and tender from the infection. Thrombophlebitis appears to be cord like. Cellulitis tends to be more diffuse than streaks. Vasculitis is unlikely to occur in the context of upper limb infection. Erysipelas is a type of cellulitis with marked lymphatic involvement and borders.
Question 10
Maria received an insect bite to her umbilicus.
Which of the following lymph nodes receive lymph from the umbilicus? Select all that apply
Deep inguinal
Superficial inguinal
Question 10 Explanation: 
This questions tests whether you know the lymphatic drainage route of the abdominal wall. The abdominal wall lymphatic drainage passes to lymph nodes groups located at the proximal part of the limbs aka axillary and superficial inguinal. The pre-aortic and mesenteric nodes drain the gastrointestinal tract itself.
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