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History and examination—points to elicit

• Onset of symptoms, whether progressing or not.

• Systemic symptoms, weight loss (>10% body weight loss in <6 months).

• Risk factors for HIV infection.

• Local or systemic evidence of infection.

• Evidence of systemic disorder such as rheumatoid arthritis.

• Evidence of malignancy; if splenic enlargement present then lym-phoreticular neoplasm is more likely.

• Specific disease-related features e.g. pruritus and alcohol induced lymph node pain associated with Hodgkin's disease.

• Determine the duration of enlargement ± associated symptoms, whether nodes are continuing to enlarge and whether tender or not. Distribution of node enlargement should be recorded as well as size of node.

Investigations

1. FBC and peripheral blood film examination.

2. ESR or plasma viscosity.

3. Screening test for infectious mononucleosis and serological testing for other viruses.

4. Imaging—e.g. chest radiography and abdominal ± pelvic USS to define 9 hilar, retroperitoneal and para-aortic nodes. CT scanning may also be helpful.

5. Microbiology—e.g. blood cultures, indirect testing for TB and culture of biopsied or aspirated lymph node material.

6. Lymph node biopsy for definitive diagnosis especially if a neoplastic cause suspected. Aspiration of enlarged lymph nodes is generally unsatisfactory in providing effective diagnostic material.

7. Bone marrow examination should be reserved for staging in confirmed lymphoma or leukaemia cases—it is not commonly a useful primary investigation of lymphadenopathy.

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