A man with generalised lymphadenopathy

A 75 year old man with Paget’s disease, hypercholesterolaemia, and hypertension presented with a three year history of multiple neck lumps, which had never been investigated and had increased in size over the past two months. He felt generally well and had no history of fever or weight loss. His appetite was normal and there was no change in bowel habit. Clinical examination showed no abnormalities and he had no shortness of breath, chest pain, lower limb oedema, joint pains, or neurological symptoms.

On examination, he had hepatomegaly (width of three fingers) and his cervical, axillary, and inguinal lymph nodes were enlarged, hard, and non-tender bilaterally. His blood count, renal function, and C reactive protein (<57 nmol/L; reference range 0-95) were normal. He had a raised erythrocyte sedimentation rate (102 mm in the first hour (28-32) and altered liver function tests (alkaline phosphatase 6.5 µkat/L (0.67-2.15), alanine aminotransferase 0.35 µkat/L (0.08-0.68), γ-glutamyl transferase 9.67 µkat/L (0.13-1.02), and total bilirubin 29.5 µmol/L (1.72-17.1). Proteinuria (0.25 g/L) was noted on urinalysis. Chest radiography showed mediastinal lymphadenopathy. Computed tomography of the thorax, abdomen, and pelvis showed enlarged mediastinal, axillary, and inguinal lymph nodes, which varied in size from 1 cm to 3 cm, with eggshell calcifications and an enlarged liver with hypodense texture.

A lymph node biopsy was done and histological analysis performed (figure⇓).