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Forum Name: Lymphoma

Question: Lymph node concern and question


 John L - Sat Dec 10, 2005 9:12 pm

I am a male, 58 years of age and in top physical condition. 6'1" 178 pounds. I walk 10 miles a day and run about 15 miles a week. I do weight training 1/2 hour each day. During my annual physical in late August, my GP (his second year in practice) said my blood work indicated anemia and he felt what he thought was a swollen lymph node in my groin. The CT scan was negative (unremarkable). He sent me to a Hematologist/Oncologist who said everything was negative and all was okay including the slightly low red count and low hematocrit because of the athletics. He said the he felt a "shotty" mass in my left groin but felt it was actually the inguinal ligament. The oncologist was puzzled by my GP's referral. That was August/Sept/ Oct.
This is probably totally unrelated ( I hope)
In November, I began hearing a pop in my right ear, behind the drum quite frequently. In late December I presented with slight sinus drainage, slight pain on right side of jaw and ear and swollen gland under right side of chin. GP said that although he could not see anything, its an infection and prescribed Augmentin for seven days. He said the entire lymph chain on the right side is enlarged.

The seven days have passed. Nothing has changed or improved. The gland is still swollen and slightly tender. There is still some slight pain on right side of jaw and ear and ear still pops. There is slightly more pain when I press in the area of the ramus of the mandible. I have an ever so slight sore throat on the right side, and some very mild pain on occasion up the right side of my face to the front of the ear. The symptoms seem to become more noticable as the day progresses. I feel wonderful when I wake up in the morning. As I think about it, I begin to notice the smptoms.

I have called my GP twice in the past two days for an appointment, but he, on both occasions said I should not see him, that it can take up to a month of the swelling to go down after an infection. He said on both occasions that if, after a month, it is still swollen, he will CT and send me to an ENT.

I have no loss of weight or appetite. No night sweats, no pallor, no fever or chills.

There is absolutely no history of cancer in any member of my family on either side. Not even a suspicious mole.

I have never had my wisdom teeth removed. A dentist told me several years ago that, "someday, you may have a problem."

Man oh man, I hate to wait a month. This is really bothering me, physiologically, specially after the first scare. To be honest, I am fearful because of his reaction back in August. Any thoughts, PLEASE. I know this is complicated but would really appreciate some additional medical thinking.

JL
 Dr. Tamer Fouad - Sun Dec 11, 2005 3:14 am

User avatar Hi John,
I see no reason for concern at all. What doctors are concerned about is unexplained lymph node enlargement as opposed to a lymph node enlargement that appears to have a clear clinical cause.

The lymph node you described is called the submandibular lymph node. It is responsible for draining the tongue, submaxillary gland, lips and mouth, conjunctivae and is commonly enlarged as a result of infections of head, neck, sinuses, ears, eyes, scalp, pharynx (much more commonly than cancer).

Regarding size: An increase in nodal size on serial examinations is significant.

Nodes are generally considered to be normal if they are up to 1 cm in diameter; however, some authors suggest that epitrochlear nodes larger than 0.5 cm or inguinal nodes larger than 1.5 cm should be considered abnormal [1,2].

Infected Lymph nodes however, tend to be:
Firm, tender, enlarged and warm. Inflammation can spread to the overlying skin, causing it to appear reddened.

Lymph nodes harboring malignant disease tend to be firm, non-tender, matted (I. e. stuck to each other), fixed (I. e. not freely mobile but rather stuck down to underlying tissue), and increase in size over time.

Following infection, however, Lymph nodes occasionally remain permanently enlarged, though they should be non-tender, small (less the 1 cm), have a rubbery consistency and none of the characteristics described for malignancy or for infection. These are also known as 'Shotty Lymph nodes'.

I understand your anxiety about your doctor, but if anything he was being over-cautious and not negligents. My impression, like his impression is that there is nothing to to it; however, given the limitations of the internet as a diagnostic tool and your anxiety about the efficiency of your doctor you may want to get checked out by another doctor.

References:
===========
1. Libman H. Generalized lymphadenopathy. J Gen Intern Med 1987;2:48-58.
2. Morland B. Lymphadenopathy. Arch Dis Child 1995; 73:476-9.
 John L - Sun Dec 11, 2005 7:07 am

Doctor,
Thank you for your time on this matter. I believe I will have another doc take a look at the lymph nodes in question. Your comments are reassuring and I certainly want to be sure that I there is nothing too serious here. The glands are still enlarged, they are still tender and I want to get them back to normal. Finding a doc here in central Florida is a real mission. There is up to six months for a GP. I guess my options are a walk in or ER which I hesitate to do. Thanks again.
 John L - Thu Dec 22, 2005 8:06 am

A week or so ago, I described to you a swollen submandibular gland that my doctor is watching. It is soft and moveable. I have slight discomfort up the right side of the jaw and into the area of the right ear. I was on augmenton for seven days with no change.

I am a 58 year old male with no family cancer history. I am in good physical condition, excercise every day and otherwise feel good. A couple of months ago, I had an abdomen and pelvic ct scan which was negative. I saw an oncologist because of mild Anemia. The oncologist reported negative findings.

Now, I have noticed that I am displaying bleeding under the surface of my facial skin when I scratch or shave with a less than sharp razor. The blood disappears in a day and does not happen all the time. It is, however of concern to me. I have no night sweats, no Rapid heart beat, no loss of appitite, no unexplained weight loss and no palor.

I have not noticed any subcutanious bleed on any other body part, other than my face.

Is it possible that the mild Anemia is the cause? I exercise alot. Walking, running, weight training.
 Dr. Tamer Fouad - Thu Dec 22, 2005 9:21 am

User avatar Dear John,
Thank you for posting your question.
The answer is no anemia is not responsible for subcutaneous bleeding or bruising. I am afraid I cannot estimate the importance of this problem online. But since this is a new symptom I strongly recommend that someone have a look at it when it does happen. Have you started taking any analgesics lately? Are you receiving any blood thinners?
 John L - Mon Jan 02, 2006 6:19 pm

Dr. I'm sorry to be a bother, but I need your guidance again. I had a head and neck CT scan last week for the swollen lymph node described above. The results were completely negative. There were no abnormalities. The gland is still swollen, but slightly smaller. My doctors nurse called with the results and said not to worry, that I am "completely healthy." I asked her if leukemia was a possibility. She said, "NO" there are lots of other things we see for leukemia.
My doctor, yesterday closed his office for a month and I am without a physician.
I still have concerns. The subcutaneous bleeding I described above is still present, on occasion. (not always). My mother bruised and bled very easily. I also experience some occasional itching on the surface of my skin. It is never deep and it happens only occasionally and is relieved with slight scratching or rubbing. I have no loss of weight or appetite. No gum bleeding and I sleep well. I am not fatigued. I exercise every day and golf frequently.

Two months ago, as described above, a hematologist/oncologist studied a blood sample and found that I was slightly anemic. My question to you is, would leukemia have been obvious to the hematologist when he looked at my blood results? I would like to re-visit the hematologist, but am concerned that without my physician to refer me, I will not be able to see him. What are the markers for leukemia that you see. There is no history of cancer in my family on either side.

I'm sorry to be such a worry wart, but I am restless about continuing symptoms. Thanks in advance

John L.
 John L - Mon Jan 02, 2006 7:05 pm

Have you started taking any Analgesics lately? Are you receiving any blood thinners?


No. The only thing I am taking that is new, is an iron pill daily suggested by the hematologist. By the way, the subcutaneous bleeding seems to be on my face only. It has been happening for about a year or so, but seems to be more prevalent lately. It is not painful
 Dr. Tamer Fouad - Tue Jan 03, 2006 1:28 am

User avatar Dear John L,
First of all congratulations! The CT results and the fact that the swelling is decreasing in size rules out anything serious in the lymph nodes.
I understand your concern about the subcutaneous bleeding. I am in no position to estimate the severity of this but if it is increasing in intesity and frequency you should have someone check it out.
As for your question regarding leukemia. As I am sure you know leukemia is a disease of the blood and it manifests itself by producing various changes in the blood film. So a CBC that does not show any of the criteria for leukemia is definitive. I would suggest that you do a follow up CBC and consult your hematologist again. When you do meet your hematologist focus on only one problem which is the subcutaneous bleeding, ask him for an explanation and his assessment of the situation.

Keep us posted.
 John L - Tue Jan 03, 2006 10:01 am

Doctor, I can see how physicians can sometimes become frustrated with patients. From time to time, we do no think clearly and and do not convey complete information, or maybe forget things that are symptomatic.

The reason I posted to you yesterday was because of a sudden bleeding under the skin on my lip after I scratched it with my fingernail. A second scratch produced the same result.
It was not until this morning did I realize that I am taking ibuprofen for tendinitis in my left arm. 600 Mg 3X per day. I did not take the ibuprofen last night or this morning and when I scratch at my lip this morning, nothing happened.

About 10 years ago, my physician, at that time, had prescribed one prophylactic baby aspirin a day. I had to stop after several weeks because of excessive bleeding from small wounds. In August of this year, I was taking ibuprofen for another exercise induced tendinitis, but had to stop because of severe widespread gastritis.

I think that ibuprofen and I do not get along. I am still going to try to get an appointment with the hematologist to be sure.

I want you to know how much I appreciate the service you offer here.
 Dr. Tamer Fouad - Tue Jan 03, 2006 10:57 am

User avatar Thank you John. Its been a pleasure.
 John L - Fri Jan 20, 2006 7:18 am

Doctor,
You are kind enough to ask us to keep you informed. I am pleased to report that a recent visit to my hematologist showed that my blood is absolutely normal. My CT study was also unremarkable. I have been given a clean bill of health, and of course I am very pleased.
Once again, I would like to commend you on this forum. It offers more support than you realize. During a worrisome time, patients embrace a conversation with a caring medical professional. Not many doctors would take the time to do what you are doing. I hope this project continues to be available.

Best Regards
John L.
Lady Lake, Florida

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