Lymphoma Cannot Be Ruled Out and Requires Urgent Investigation
This patient with a groin mass, fatigue, and pruritus requires immediate workup for lymphoma regardless of the winter season, as these symptoms represent classic warning signs that should never be dismissed as seasonal.
Critical Red Flags Present
The combination of symptoms in this patient raises significant concern for lymphoma:
- Itching at night in association with fatigue is highly suggestive of lymphoma, particularly when accompanied by an enlarged mass 1
- Enlarged lymph nodes or masses should be referred for excision or ultrasound-assisted core biopsy to establish diagnosis 1
- The groin mass represents palpable iliac or inguinal lymphadenopathy, which is abnormal and warrants investigation 2
Why Winter Season Cannot Explain These Symptoms
While patients may attribute dry, itchy skin to winter weather, the clinical context here is fundamentally different:
- Lymphoma-associated pruritus is characterized by nocturnal itching that occurs without primary skin lesions 1
- When pruritus occurs with fatigue and a mass, this represents a constellation of symptoms that demands exclusion of malignancy 1, 3
- Simple seasonal xerosis (dry skin) does not cause systemic fatigue or lymphadenopathy 1
Mandatory Immediate Workup
The groin mass requires tissue diagnosis through excisional biopsy or ultrasound-guided core biopsy as the first priority 1:
- Fine needle aspiration alone is insufficient for initial lymphoma diagnosis 1, 4
- An excisional lymph node biopsy is the preferred diagnostic method 3, 4
Initial laboratory investigations must include 1:
- Complete blood count with differential and blood film
- Lactate dehydrogenase (LDH) - elevated in lymphoma 3, 5
- Erythrocyte sedimentation rate (ESR)
- Comprehensive metabolic panel
Assess for B symptoms systematically 3, 5:
- Unexplained fever >38°C (>101°F)
- Unintentional weight loss >10% within 6 months
- Drenching night sweats requiring clothing/bedding changes
Differential Considerations Beyond Lymphoma
While lymphoma must be excluded first, other haematological causes of pruritus with masses include 1:
- Polycythemia vera (PV) - characterized by aquagenic pruritus (itching triggered by water contact) 1
- If PV suspected, check JAK2 V617F mutation (present in up to 97% of cases) 1
Critical Pitfall to Avoid
Never attribute constitutional symptoms and lymphadenopathy to benign seasonal causes without excluding malignancy first 1, 3. The combination of:
- Palpable groin mass
- Fatigue (not relieved by rest)
- Pruritus (particularly if nocturnal)
...represents a clinical scenario where lymphoma remains high on the differential until proven otherwise 1, 3.
Lymphoma Subtypes and Pruritus
Pruritus is most strongly associated with Hodgkin lymphoma, though it can occur in non-Hodgkin lymphoma 1, 6:
- Hodgkin lymphoma more commonly presents with B symptoms including pruritus 3
- Generalized pruritus is unusual in most non-Hodgkin lymphoma subtypes 1
- Haematological causes account for approximately 2% of all generalized pruritus cases 1
The definitive treatment of the underlying lymphoma invariably resolves the associated pruritus, making accurate diagnosis the therapeutic priority 1, 6.