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Swollen Lymph Nodes

The most common reason for seeing someone with swollen lymph nodes and fever is mononucleosis. It is a common disorder. It is usually seen in children, adolescents and young adults, so we think about mono as a disease of young people. Once in awhile, we do see it in an older person. Mononucleosis can occur in older people - they can have fatigue, fevers, lymphadenopathy, elevated liver function tests and sore throat - but they can't conceive of it as being mono. But even older people can get mono. The manifestations are protean - they're from the god Proteus - they are the shape shifter of gods - so they have all kinds of elements that don't look like they involve a particular organ more than another, but they include fever, fatigue, lymphadenopathy, sore throat. The white cell production is altered in a way that results in an increased number of so-called atypical lymphocytes and often a reduction in polys. We all remember doing the smear tests in school, looking for normal white cells.

If your laboratory relies on a machine to do all of its differential counts, or if a "normal white count differential" is done with a machine, you will never find these. So not finding them doesn't mean that they aren't there, it means that the lab tech never looked at them and the machine said that everything was fine. The other thing about the machine is that it shows nucleated red blood cells.

When you are suspicious of mono, you can often do simple tests to confirm your suspicion. Of course, one thing you want to do is a CBC with a differential, because obviously in a person with a fever and lymphadenopathy, it seems like a straightforward thing to do - and look for the decreased neutrophil count and decreased atypical lymphocytes.

Now in the older adults, say those over 40, EBV is less common as an acute disease but it can occur. Usually the sore throat part is a less prominent part of the disease, so you don't have that clue. You get more liver abnormalities. Now, we are living in the hepatitis era. Everyone is getting hepatitis serologies A through Z - you get the total alphabet hepatitis serologies.

If a person has a story that they have had mono and now they have a syndrome that looks just like mono and in fact the blood tests confirm that it is acute mono, could that be a recurrence or some kind of new infection, or can you get it twice? This is a hard question to answer. We know that once you get Epstein-Barr infection you keep it for life; it is sort of like a little keepsake - you can't get rid of it - it is something that you have forever.

The most common test for EBV is the heterophile antibody test, because that can be ordered in almost any laboratory; it is pretty standardized now and the Monospot brand is the one we use in our laboratory; you probably have something similar in your lab. If you really want to get particular about it, though, you might want to do specific tests for EBV. Now, if you are really a masochist, you could probably spend the rest of your life trying to figure out every EBV test and what it mean, but I wouldn't encourage you to do that. Basically, there are just two different antigens that you should be aware of.

Now regarding treatment, there really isn't any treatment for most people, because they just get better. Often times, the hardest treatment is encouragement. I think this is really an important point. If someone says that they feel really rotten, I accept that. But talking about it forever and wallowing in it probably isn't going to help matters, so some people need to be told that yes, they feel rotten and you are sorry about that, but that if they give it some time they will feel stronger.

Now the one time you want to worry is when every once in awhile someone has so much lymphatic excitement that the lymph tissue in the tonsils begin to meet in the middle. You may have to give people steroids for that. People have talked about spleen enlargement as maybe another indication for steroids, although I don't think you have to worry about that in most people.

I said earlier that once you have EBV, you have it for life. But I don't think it explains away people's sense of fatigue and anhedonia and poor functionality. I'll give you an example. There is a certain scam that you have probably encountered among brokers. The brokers take a stock which is of little significance and they call one hundred people and say that this stock is going to go up by 20 points.

Suppurative infections are the classic ones that cause localized regional adenopathy and usually you know where the infection is. If there is lymphangitis as well as lymphadenopathy - if you have tender lymph nodes here and a big red streak up the arm - it sounds like lymphangitis. You should definitely think about Strep as one of the most important causes of lymphangitis.