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Also written as Hodgkin lymphoma, Non‑Hodgkin lymphoma.

Lymphoma presents with systemic and nodal signs that vary by subtype and disease burden. Recognising patterns helps differentiate it from infection, metastasis, and autoimmune disease.

Overview

Lymphoma is a malignant proliferation of lymphocytes that can arise in lymph nodes, extranodal sites, or both. Clinical presentation reflects tumor load, location, and host response.

• Painless lymphadenopathy is the classic initial sign.
• B symptoms (fever, night sweats, weight loss) indicate systemic activity.
• Extranodal disease may mimic organ‑specific pathology.

Key concepts

Distinguish Hodgkin (Reed‑Sternberg cells, contiguous spread) from non‑Hodgkin (heterogeneous subtypes, non‑contiguous spread). Staging uses the Ann Ann system (I–IV) based on nodal regions and organ involvement.

• Contiguous nodal spread → think Hodgkin.
• Rapidly enlarging mass, B symptoms, high LDH → think aggressive NHL.
• Extranodal involvement of GI, CNS, or bone marrow suggests advanced stage.

Clinical relevance

Early recognition guides urgent biopsy, staging investigations, and timely referral to oncology, which improves survival especially in low‑resource settings.

• Excisional lymph node biopsy: Provides histology and immunophenotype; confirms subtype. If unavailable, fine‑needle aspirate with flow cytometry is an alternative.
• PET‑CT: Staging and response assessment; if not accessible, contrast CT of chest/abdomen/pelvis plus bone‑marrow biopsy can be used.
• Serum LDH: Elevated LDH correlates with tumour burden and aggressive disease; normal LDH does not exclude lymphoma.

• Any persistent, unexplained lymph node >2 cm warrants tissue diagnosis.
• B symptoms plus night sweats in a febrile patient should raise suspicion for lymphoma over TB.
• HIV‑positive patients often present with high‑grade NHL.

Exam pearls

Examiners test ability to prioritize investigations, differentiate from mimics, and choose appropriate initial management.

• Always consider lymphoma in painless, firm, rubbery nodes >1 cm.
• B symptoms are red flags for systemic lymphoma rather than simple infection.
• In HIV patients, CD4 count guides urgency of biopsy and prophylaxis.

Common mistakes

Students often over‑rely on imaging or miss the need for tissue diagnosis, and confuse lymphoma signs with TB or metastatic cancer.

• Assuming fever rules out lymphoma – many have fever.
• Treating presumed infection without biopsy delays therapy.
• Ignoring extranodal symptoms that may be the first clue.

Questions an examiner may ask

• A 45‑year‑old with painless cervical nodes and night sweats – what is your next diagnostic step? — Excisional biopsy to obtain histology and immunophenotype.
• Patient with HIV, CD4 150, presents with a rapidly enlarging axillary mass – which lymphoma subtype is most likely? — High‑grade B‑cell NHL (e.g., diffuse large B‑cell lymphoma).
• How does the presence of B symptoms alter staging? — Up‑grades to stage B, indicating systemic disease and influencing treatment intensity.
• Why is fine‑needle aspiration alone insufficient for Hodgkin lymphoma? — It often misses Reed‑Sternberg cells and lacks architecture needed for diagnosis.
• In a low‑resource setting without PET, how would you stage suspected lymphoma? — Use contrast CT of chest/abdomen/pelvis, ultrasound of accessible nodes, and bone‑marrow biopsy.
• What drug class is avoided in Hodgkin lymphoma with pulmonary involvement and why? — Bleomycin, due to risk of pulmonary toxicity exacerbated by lung disease.
• A patient with persistent fever and lymphadenopathy is treated for TB but does not improve – what should you consider? — Re‑evaluate for lymphoma; obtain tissue diagnosis.
• How does elevated LDH influence prognosis? — High LDH signals high tumour burden and aggressive disease, indicating poorer prognosis.

When to seek help

• Unexplained, rapidly enlarging lymph node >2 cm
• Fever, night sweats, and >10 % weight loss over 6 months
• New neurological deficits with known lymphadenopathy

Quick questions

Can lymphoma present with only skin lesions?

Yes, primary cutaneous lymphoma can manifest as plaques or nodules without nodal disease.

Is a painful lymph node ever lymphoma?

Rarely; pain usually suggests infection, but lymphoma can be painful if there is necrosis or rapid expansion.

Do all patients need PET‑CT?

PET‑CT is preferred for staging and response, but CT plus bone‑marrow biopsy is acceptable when PET is unavailable.