There are very many causes of swollen glands (lymphadenopathy), but in general it is possible to narrow the list of possible causes down to a manageable few by careful history and examination. Age, geography (or travel history) and distribution of enlarged glands have a considerable influence on the differential diagnosis.
- Local Infection (e.g. URTI, Tonsillitis)
- Generalised Viral Infection (e.g. Glandular Fever, Rubella)
- Malignancy: Secondary Metastasis
- White Cell Malignancy: Lymphoma, Leukaemia, Myeloma
- Cat Scratch Fever (Especially in Children)
- Rheumatoid Arthritis
- Tropical/Subtropical Sexually Transmitted Infection: Lymphogranuloma Venereum (LGV), Granuloma Inguinale (GI)
- Syphilis (Primary or Secondary)
- HIV: AIDS and AIDS-Related Complex (ARC)
- Tropical Infections: Leprosy, Filariasis, Trypanosomiasis, Tularaemia
- Drug Reactions (e.g. Phenytoin, Penicillins, Sulphonamides)
- Lyme Disease
Key distinguishing features of the most common diagnoses
|Local Infection||General Viral||Metastases||WC Malignancy||Septicaemia|
|Persistent (>6 Weeks)||No||No||Yes||Yes||No|
|Regional Nodes Only||Yes||No||Yes||Possible||No|
Likely: None if localised; FBC and ESR/CRP if generalised.
Possible: Paul–Bunnell test, CXR, acute and convalescent sera, HIV testing, lymph node biopsy.
Small Print: Autoimmune blood tests, syphilis and Lyme disease serology, cultures and scrapings for LGV and GI, bronchoscopic biopsy or nodal aspiration, CT scan, indirect fluorescent antibody blood test for Bartonella henselae.
- FBC: Atypical lymphocytes reflect acute viral infection; many of the causes listed will result in a raised WCC and ESR/CRP. Hb may be low in malignancy and connective tissue disease; WCC and film may show evidence of lymphoma or leukaemia.
- Paul–Bunnell test: To confirm glandular fever.
- CXR: May reveal carcinoma, TB, lymphoma, sarcoid and the source of septicaemia.
- Serology: Acute and convalescent sera may confirm specific viral infection.
- Bronchoscopic biopsy or nodal aspiration: For possible sarcoid.
- Abdominal and chest CT scan is a sensitive test to detect pelvic, para-aortic, mesenteric, hilar or paratracheal node enlargement (e.g. in lymphoma).
- Autoimmune blood tests: May help in diagnosis of connective tissue disorder.
- Culture/scrapings (GUM clinic): For LGV and GI.
- Syphilis and Lyme disease serology, HIV testing: For syphilis, Lyme disease and AIDS.
- Indirect fluorescent antibody test for B. henselae: This is the causative organism in cat scratch disease.
- Lymph node biopsy may be necessary to reach a definitive diagnosis.
- Normal cervical lymph nodes are often palpable in children; they swell with URTIs and may be presented by anxious parents fearing significant disease.
- Remember geography: A young adult from the UK with persistent cervical nodes is likely to have Epstein–Barr virus (EBV) infection while, in Africa, the likeliest diagnosis would be tuberculosis. Swollen groin glands in the latter group might be caused by LGV or GI.
- Patients often attach great significance to swollen glands. It is worth explaining that lymphadenopathy usually represents a normal part of the immune system’s defence against infection and does not in itself require attention from the doctor unless there are unusual features.
- Unexplained and persistent cervical lymphadenopathy in the middle-aged and elderly should prompt urgent ENT assessment to exclude nasopharyngeal carcinoma.
- An enlarged left supraclavicular node (Troisier’s) in a patient with weight loss suggests gastrointestinal carcinoma.
- Generalised, persistent lymph nodes with weight loss and sweats in a young adult suggest glandular fever, lymphoma or AIDS.
- A slowly enlarging, non-tender cervical node in an unusual site is likely to be malignant.