In a 78-year-old patient with persistent pruritus, isolated LDH elevation, normal complete blood count, no B symptoms, and a family history of non‑Hodgkin lymphoma, is a contrast‑enhanced CT scan indicated?

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Last updated: September 20, 2026 • View editorial policy

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Yes, contrast-enhanced CT is indicated in this patient.

Given the combination of persistent pruritus, isolated LDH elevation, family history of NHL, and age 78, you should proceed with contrast-enhanced CT imaging to evaluate for occult lymphoma, despite the normal CBC and absence of B symptoms.

Clinical Reasoning

This patient presents with several concerning features that warrant aggressive investigation:

Why CT with Contrast is Warranted

The British Association of Dermatologists guidelines 1 specifically recommend that patients with generalized pruritus and suspicion of haematological involvement should have initial investigations including full blood count, blood film, lactate dehydrogenase and ESR. Your patient has already demonstrated an abnormal LDH, which is a red flag.

Key point: While the guidelines note that pruritus "is unusual in other types of lymphoma, such as non-Hodgkin lymphoma (NHL)" 1, this does not mean it never occurs. In fact, a 2022 population-level cohort study 2 found that patients with undifferentiated pruritus had significantly increased 1-year risk of non-Hodgkin lymphoma (RR 2.35,95% CI 1.96-2.82), with the highest risk in the first 12 months.

The LDH Elevation Changes Everything

The isolated LDH elevation is particularly concerning. While the 2022 study 2 found that LDH had limited diagnostic utility as a screening tool in unselected pruritus patients, your patient is not unselected - they have a positive family history and persistent symptoms. The guidelines 1 explicitly list LDH as part of the recommended workup when haematological involvement is suspected.

Why Contrast is Necessary

Contrast-enhanced CT is superior to non-contrast imaging for lymphoma evaluation. A 2004 study 3 comparing PET/CT with contrast-enhanced CT found sensitivities of 94% vs 88% for lymph node involvement and 88% vs 50% for organ involvement. While PET/CT was superior overall, this demonstrates that contrast enhancement significantly improves detection compared to non-contrast imaging.

Additionally, a 2010 study 4 showed that lymphomatous lymph nodes have significantly lower mean enhancement values than normal nodes (77.9 vs 93.4 HU at 90 seconds, sensitivity 91%), making contrast essential for characterization.

The Clinical Algorithm

For this 78-year-old patient:

  1. Immediate imaging: Order contrast-enhanced CT of neck, chest, abdomen, and pelvis

    • Look specifically for: enlarged lymph nodes (>1 cm short axis), internal necrosis, infiltrative margins, matted lymphadenopathy 5
    • NHL nodes may show lower enhancement than normal nodes 4

  2. If lymphadenopathy is identified: Refer for ultrasound-guided core biopsy or excisional biopsy 1

    • Do not delay - early tissue diagnosis is critical

  3. If imaging is negative but symptoms persist: Consider skin biopsy from the trunk 1, as patients may rarely present with pruritus and normal-appearing skin who subsequently prove to have cutaneous lymphoma

Common Pitfalls to Avoid

  • Don't be falsely reassured by the normal CBC - lymphoma can present with normal blood counts, especially in early disease or when confined to lymph nodes/organs
  • Don't dismiss the family history - while not mentioned in the guidelines, this adds to the pre-test probability
  • Don't order non-contrast CT - you will miss critical enhancement patterns that help distinguish lymphomatous from reactive nodes
  • Don't wait for B symptoms to develop - pruritus may be the only presenting symptom, and early detection improves outcomes

Age Considerations

At 78 years old, this patient is at higher risk for lymphoma, and the case report 6 specifically describes a 78-year-old woman with cutaneous PTCL where contrast-enhanced CT of the neck demonstrated multiple enlarged, partially necrotic lymph nodes. The report emphasizes the importance of including lymphoma in the differential for new symptoms in elderly patients with suspected hematologic malignancy.

Bottom line: The combination of persistent pruritus + elevated LDH + family history + age 78 creates sufficient suspicion to warrant definitive imaging. The guidelines support this approach, and contrast enhancement is essential for proper lymph node characterization and detection of occult disease.

References

4
Research

Enhancement characteristics of lymphomatous lymph nodes of the neck.

Acta radiologica (Stockholm, Sweden : 1987), 2010

5
Research

Imaging Features of Double-hit Lymphoma on Contrast-enhanced Neck CT.

Journal of computer assisted tomography, 2026

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