Cases corner – 19 years old with lymphadenopathy

10th January 2019

Mr X, a 19 year old man, presents to you with a one week history of lumps in his groin. He is otherwise well, denying any fever, sore throat, appetite loss, pain, urethral discharge, urinary frequency or dysuria. On examination you note generalised lymphadenopathy (cervical, axilla and groin). There is no evidence of pharyngitis and his spleen is not palpable.

What would you do next?

  1. Reassure him and offer safety-netting advice if he deteriorates
  2. Request a very urgent full blood count
  3. Request an urgent blood film
  4. Refer the patient along a 2-week-wait pathway to haematology
  5. Refer the patient immediately to hospital

This patient’s presentation is concerning for possible leukaemia due to the presence of unexplained generalised lymphadenopathy.

Due to the patient’s age, you may initially suspect a diagnosis of infectious mononucleosis caused by the Epstein Barr Virus (EBV). However, this typically presents with two other cardinal symptoms: fever and sore throat. This patient denies these symptoms and makes the diagnosis of infectious mononucleosis unlikely. Therefore, it would not be appropriate to offer reassurance in the first instance.

The NICE NG12 Guidelines advise that you should consider a very urgent full blood count (within 48 hours) to assess for leukaemia in adults with any of the following:

  • Pallor
  • Persistent fatigue
  • Unexplained fever
  • Unexplained persistent or recurrent infection
  • Generalised lymphadenopathy
  • Unexplained bruising
  • Unexplained bleeding
  • Unexplained petechiae
  • Hepatosplenomegaly

Although a blood film is likely to be performed, most labs across the country will automatically request a blood film if the full blood count is suggestive of leukaemia. The white cell count differential is highly sensitive for leukaemia and should be done in the first instance. A blood film may show blast cells or other abnormalities, but patients usually require a bone marrow biopsy to confirm the diagnosis.

Emergency admission for suspected haematology cancer patients is usually reserved for patients with signs of leukaemia which suggest emergency treatment is required (i.e. children and young people with unexplained petechiae or hepatosplenomegaly). Similarly, a 2-week-wait referral would not usually be required in the first instance.