About Lymphoma > Symptoms & Complications of Lymphoma

Last update: 09/05/2012

TOPICS
General Symptoms | B-symptoms | Other symptoms - neuropathy | Reporting Symptoms |
Disease Direction Indicators | Blood counts | Ascites |  Cutaneous (skin) | Itching (Pruritus) | Fatigue | Lymphedema | Nosebleed | Night Sweats | Pain | Pleural effusions  | Performance Standards | Restless Leg |
 Weight Loss (cachexia)

General symptoms

Understanding the symptoms of lymphoma lets you better participate in your care and treatment. 

Patients often report that it's difficult to distinguish between important symptoms and those that may be unrelated to lymphoma. 

Some Definitions:

Anemia absolute reduction in the quantity of the oxygen-carrying pigment hemoglobin (Hgb) in the circulating blood.

Leukopenia low white blood cell count (WBC) less than 5.0 X 109/L

Lymphadenopathy   abnormal  increase in size of lymph nodes. 

Thrombocytopaenia  platelet count of less than 150 X 109/L)

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General symptoms of lymphoma

Alphabetical List | B-Symptoms | Systemic Symptoms  |
 A Systems Checklist | Printable Symptoms Checklist (PDF)

Lymphoma is often first noticed as painless enlarged lymph nodes (adenopathy or lymphadenopathy). However, most of the time, enlarged lymph nodes do not mean lymphoma. Only a biopsy and subsequent pathology evaluations of the tissue can determine or exclude the diagnosis of lymphoma.

See Lymphadenopathy: Differential Diagnosis and Evaluation Robert Ferrer, M.D., M.P.H. - American Family Physician for an excellent description of lymphadenopathy, as well as the many benign causes of enlarge lymph nodes.

Symptoms can vary widely depending on the type of lymphoma, and where the lymphoma is actively growing. Symptoms related to bone marrow dysfunction, such as anemia (low red blood cell count), are not as common when the disease is first diagnosed, but are most likely to present in later stages of the disease and also as side effect of some treatments. MALT lymphomas may present as an upset stomach; or a change in bowel movement could be caused by an enlarged lymph node.

In the News

Medscape: Mindfulness Training Can Improve Symptoms, Mood After HSCT

Symptom of Lymphoma or Unrelated?

Following a diagnosis of a lymphoma the mind often races -- we are prone to interpret each sensation as a sign of progression or relapse.  

On this, Judy of WebMagic wrote:

Lots of things go intermittently wrong with your body especially as you get older. When it occurs, get it checked out. If they say nothing is wrong, give it a little time. Lots of times it just resolves. But, if it doesn't or gets worse, go back the same Dr.. Explain the situation. Lots of times, we start to feel something before it can be detected by Drs., tests, etc. and it takes time for symptoms to progress to when they are detectable.

At that point, your doctor should put together a plan for you. Sometimes the plan is just wait, it should resolve. Other times, its tests or treatment. For my RA diagnosis this waiting phase was 4 years. But, eventually my symptoms became more evident. When you see the doctor, the doctor is ruling out things as he is examining you and you are in wait mode. That is good.

And, if you can't get a plan from this Dr. that you feel comfortable with, then you go see another Dr. At some point, you get to a place you are comfortable.  ... I would schedule a follow up with the GP, to review the test results, review your current symptoms, and put together an appropriate plan.

Reporting symptoms:

It can be difficult at times to identify the meaning of a symptom. Some symptoms may be common to certain stages of lymphoma and to specific treatments. But you may have or develop other medical conditions and illnesses that are unrelated to lymphoma, such as flu or an ulcer.  

When informing your doctor about a symptom also describe: 

1. the intensity using a scale of 1 to 10

2. for visible symptoms, describe the size and appearance   

3. when it started

4. how long it has lasted

5. if it waxes and wanes 

6. the medications and supplements you may be taking and when you started taking them 

7. how the symptom might change when you change position

8. if the symptom is associated with meals or specific foods

9. the time of day the symptom might be most intense
   
   These and other like details can assist your doctor in identifying the possible cause or causes, or if further tests are warranted.  

NEWS: Talking to Your Doctor about Symptoms http://bit.ly/dgctDj

"Because symptoms are what you experience, your healthcare providers can only know about your symptoms if you tell them. This puts you in the unique position of being the symptoms expert. " by Charles S. Cleeland, PhD, with Diana Lazzell

Also see our Symptoms Checklist (PDF)
AND Monitoring Indolent Lymphoma

Regarding fatigue: Clinical signs of anemia - changes in performance - would be important to report, such as fatigue, shortness of breath on exertion, general weakness - but these are difficult to be aware of when a condition comes on gradually - which is another reason regular exercise is a very good idea, as you will more readily notice a decrease in performance when you do regular activities, (could do this yesterday, but not today). Such reports on performance will be of more use to our doctors as well, compared to reporting "I feel tired."

Alphabetical list of common symptoms:

Unexplained and persistent:

	Anemia - low red blood count* secondary to bone marrow involvement that can inhibit blood cell production.
	Appetite loss
	Fatigue (see also anemia) secondary to bone marrow involvement that can inhibit blood cell production.
	Fever
	Flu-like symptoms - aches, fever, chills
	Infections associated with low white count* secondary to bone marrow involvement that can inhibit blood cell production.
	Metabolic - such as high calcium
	Night sweats - drenching
	Pain Depending on the anatomic location that is secondary to pressure to bone or organs, or obstruction of bodily functions
	Skin - Itchy skin (purititis); red patches
	Skin - Jaundice - yellowish tinge (related to liver function)
	Swollen and painless lymph nodes
	Swollen spleen or liver
	Thrombocytopenia - low platelets (bleeding)*  secondary to bone marrow involvement that can inhibit blood cell production.
	Weight loss
	So called "b-symptoms" are common. Onset of b-symptoms may suggest that the lymphoma is progressing.

B-symptoms include unexplained and persistent: 

	Fever and chills
	Drenching (change the sheets_ night sweats
	Fatigue
	Pruritus - skin itchiness
	Weight loss

Other symptoms related to area of involvement:

	Localized pain may occur depending on the location of tumors.
	"If lymphoma occurs in the stomach or intestines, they may have gastrointestinal bleeding, a feeling of fullness, or abdominal swelling.
	Lymphoma arising in the central nervous system (uncommon) can cause neurological symptoms such as partial paralysis, seizures, confusion, and memory loss.
	Lymphoma in the chest can cause coughing, shortness of breath, and chest discomfort." 1  (MSKCC)
	Swelling of limbs

Peripheral neuropathy (uncommon)

Muscle Nerve. 2005 Mar;31(3):301-13.

Lymphoma and peripheral neuropathy: a clinical review.
Kelly JJ, Karcher DS.

Department of Neurology, The George Washington University Medical Center, 2150 Pennsylvania Avenue NW, Washington, DC 20037, USA.

Abstract
Lymphoma occasionally affects the peripheral nervous system. When it does, the diagnosis can be elusive since many patients present without known lymphoma. Most peripheral nerve complications are due to non-Hodgkin's lymphoma (NHL), which infiltrates nerves causing axonal damage. This disorder can affect nerve roots and cranial nerves, often associated with lymphomatous meningitis. NHL may also infiltrate peripheral nerves and cause plexopathy, mononeuropathy, or generalized neuropathy. These neuropathies may resemble an asymmetric mononeuropathy multiplex or a generalized disorder such as chronic inflammatory demyelinating polyradiculoneuropathy. When NHL infiltrates diffusely, the term neurolymphomatosis is used. Hodgkin's lymphoma (HL), by contrast, rarely infiltrates nerves. More often, HL causes immunological disorders of the peripheral nervous system such as inflammatory plexopathy or Guillain-Barré syndrome. Other rare lymphomas such as intravascular lymphoma and Waldenstrom's macroglobulinemia can also affect peripheral nerves in specific ways. In addition, other malignant and nonmalignant lymphoproliferative disorders enter into the differential diagnosis of lymphomatous neuropathy. This review discusses the multiple peripheral nerve presentations of lymphoma from the clinician's point of view and provides a guide to the evaluation and diagnosis of these uncommon, challenging disorders.

PMID: 15543550   http://www.ncbi.nlm.nih.gov/pubmed/15543550

See also Neurological complications of lymphomas  http://www.ncbi.nlm.nih.gov/pubmed/17151523
 

General symptoms may include:

	flu-like symptoms such as aches and pains.
	Frequent infections from depressed immunity.

Since the symptoms of lymphoma are common to both minor and serious medical conditions, the diagnosis of lymphoma (which requires a biopsy) is often delayed.

So called systemic symptoms, such as fever, night sweats, weight loss in excess of 10%, or asthenia, are infrequent at presentation of the disease but can be observed in  later stages. Progression to an intermediate-grade or high-grade lymphoma should be considered when a patient develops systemic symptoms.  

Monitoring blood for increasing levels of LDH and Human beta-2 microglublin is commonly used to monitor progression. See LDH | Human beta-2 microglublin

A systems-based checklist: 

My appointments with my oncologist include the following review of systems which I answer Yes or No for each individual symptom and add comments if necessary:

Do you now, or have you had, any problems related to the following systems?

	Constitutional Symptoms: Fever, Chills, Headache, Other
	Eyes: Blurred Vision, Double Vision, Pain, Other
	Allergic/Immunologic: Hay fever, Drug Allergies, Other
	Neurological: Tremors, Dizzy Spells, Numbness/Tingling, Other
	Endocrine: Excessive Thirst, Too Hot/Cold, Tired/Sluggish, Other
	Gastrointestinal: Abdominal Pain, Nausea/Vomiting, Heartburn, Other
	Cardiovascular: Chest Pain, Varicose Veins, High Blood Pressure, Other
	Integumentary: Skin Rash, Boils, Persistent Itch, Other (an organ system that protects the body from damage)
	Musculoskeletal: Joint Pain, Neck Pain, Back Pain, Other
	Ear/Nose/Throat/Mouth: Ear Infection, Sore Throat, Sinus Problems, Other
	Genitourinary: Urine Retention, Painful Urination, Urinary Frequency, Other
	Respiratory: Wheezing, Frequent Cough, Shortness of Breath, Other
	Hematologic/Lymphatic: Swollen Glands, Blood Clotting Problems, Other
	Psychological: Are you generally satisfied with your life?, Have you considered suicide?    __________________ Provided by Sylvia (WebMagic)

Resources:

General symptoms: 

1. MSKCC

2. Oncology Channel

3. Pain management

Disease Direction indications

Disease Direction Indication

Also see Lab Tests

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Increasing or decreasing lab values may help to gauge progression or response to treatment. However, location of disease can affect interpretation of the indicators provided here. Therefore, it's important to consult with your doctor about questions you may have.

Increased levels: ALT (sSGPT), Alkaline Phosphatase, AST (sGOT), Beta2-microglobulin, BIlirubin, Total Calcium, Creatinine, LD (LDH), Lymphocytes, Monocytes, Sodium, BUN, Uric Acid

Decreased levels: Albumin, Cholesterol, Globulin Iron, Total MCH, MCHC, MCV, Protein

SOURCE: NHL disease-specific disease Lab pattern indications  CellMate Wellness

Abnormal Blood Counts

Abnormal Blood Counts

Also see
Low Blood Counts

Complete Blood Count Test

Anemia  
(low red blood cells)

Neutropenia
(low white cells)

Thrombocytopaenia
(low platelets)

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Blood counts cannot be reliably used to diagnose disease or monitor it, but abnormal counts are sometimes associated with lymphomas, leukemias, disease progression, or the side effects of treatment.  

Leukocytosis  emedicine.com   "refers to an increase in the total number of white blood cells (WBCs) from any cause. From a practical point of view, leukocytosis traditionally is classified according to the component of white cells that is contributing to an increase in the total number of white cells. Thus, leukocytosis may be caused by an increase in (1) neutrophil count (ie, neutrophilia), (2) lymphocyte count (ie, lymphocytosis), (3) monocyte count (ie, monocytosis),  (4) eosinophilic granulocyte count (ie, eosinophilia), (5) basophilic granulocyte count (ie, basophilia), or (6) immature cells (eg, blasts).  A combination of any of the above may be involved."

Leukopenia  Merck Manual   "is usually characterized by a reduced number of blood neutrophils, although a reduced number of lymphocytes, monocytes, eosinophils, or basophils may also contribute to the decreased total cell count. Neutropenia accompanied by monocytopenia and lymphocytopenia is often a more serious disorder than neutropenia alone."

Ascites (not common)

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TOPIC SEARCH: PubMed | Wikipedia.org 

Ascites is an excess of fluid in the membrane lining of the abdomen (the peritoneal cavity). Lymphoma might cause ascites by obstructing the lymphatic system. To relieve symptoms and diagnose the cause, a peritoneal fluid tap may be performed. Successful treatment of the lymphoma can resolve this problem.

"Ascites usually can be detected clinically by the presence of fullness in the flanks, shifting dullness, generalized abdominal distention with a fluid wave, and umbilicus eversion. In obese patients, moderate amounts of ascitic fluid may be difficult to detect. Ultrasound typically is performed to confirm the diagnosis in obese patients, because it can detect as little as 100 mL of fluid in the peritoneal cavity. Accumulation of fluid is first detected in Morison's pouch, then in the paracolic gutters; eventually, generalized ascites is noted." 
postgradmed 

Diagnosis "may be based on physical examination if there is a large amount of fluid, but imaging tests are more sensitive. Ultrasound and CT reveal much smaller volumes of fluid (100 to 200 mL) than does physical examination. Spontaneous bacterial peritonitis (SBP) (an infection of ascitic fluid) is suspected in a patient with ascites who also has abdominal pain, fever, or unexplained deterioration.

Diagnostic paracentesis (see Diagnostic and Therapeutic GI Procedures: Abdominal Paracentesis) should be performed if ascites is newly diagnosed, if its cause is unknown, or if SBP is suspected." The rare milky (chylous) ascites is most common with lymphoma.  Merck manual

 

	About Ascites   Medline Plus | Merck manual | Answers.com
	"Chylous ascites is the extravasation of milky chyle into the peritoneal cavity. This can occur de novo as a result of trauma or obstruction of the lymphatic system. Moreover, an existing clear ascitic fluid can turn chylous as a secondary event."  Emedicine
	Case Report: Intraperitoneal rituximab: an effective measure to control recurrent abdominal ascites due to non-Hodgkin's lymphoma  Springer-Verlag 2002
	Intraperitoneal Rituxan: Weight loss - unexplained (Cachexia)
	Peritoneal fluid analysis (draining the fluid to relieve discomfort and diagnose cause)  Medline Plus

Cutaneous (skin)

Also See 
Cutaneous Lymphoma

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Cutaneous lymphomas can present on anywhere on the skin.

 
Image of Cutaneous B-Cell Lymphoma - Large Cell Type - Trunk
Click to enlarge

Source: Dermatologic Image Database

	Lymphoma - Cutaneous B-Cell
	Cutaneous B-Cell Lymphoma Large cell Type - Closeup of Right Scapular Area of Back
	Cutaneous B-Cell Lymphoma - Large Cell Type - Right Scapular Area of Back - Detail of 2

Source: Aafp.org:

T-Cell Lymphoma Presenting as Benign Dermatoses - includes images  aafp.org

Itching (Pruritus)

Itching (Pruritus)

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TOPIC SEARCH: PubMed

Pruritus, also known as itch, is a common symptom of lymphoma.
 

	Pruritus as a manifestation of systemic disorders. Cutis. 1978 Jun;21(6):873-80. PMID: 657843  PubMed
	Efficacy and safety of naltrexone, an oral opiate receptor antagonist, in the treatment of pruritus in internal and dermatological diseases. J Am Acad Dermatol. 1999 Oct;41(4):533-9. PMID: 10495371  PubMed
	Severe pruritus should be a B-symptom in Hodgkin's disease. Cancer. 1983 May 15;51(10):1934-6. PMID: 6831358  PubMed
	Itch: scratching more than the surface. QJM. 2003 Jan;96(1):7-26. Review. PMID: 12509645  PubMed

Night Sweats

Drenching Night Sweats

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Drenching night sweats is one of the so-called b-symptoms associated with lymphomas.  This type usually " involves the entire body and are not confined to a specific hour during the night. 

What causes night sweats in lymphoma? There does not appear to be a definitive answer. One possible mechanism behind night sweats is that the progression of lymphoma, and the body's way of fighting infection, have some things in common - both may require the mobilization of immune cells and cytokines (such as interferon, Interleukin); and that these immune activities might account for causing night sweats, fever, and achy muscles.  

Your doctor will look at the possible meaning of night sweats in the context of other clinical symptoms and test results.  It can be a sign of progression or transformation, depending on the severity and frequency.  For this reason we believe it's prudent to notify your doctor when you have frequent night sweats to be sure. 

Resources:

Diagnosing Night Sweats  aafp.org | Stanford.edu

Hot and Bothered By Night Sweats  MSN Great tips by Dr. Rob for MSN Health & Fitness: "Needless to say, you as the patient can play a key role in narrowing down the diagnosis by providing key information to your physician. This would include: How long have your night sweats occurred (days, weeks, months)? Do they occur only at night or do you experience drenching sweats at other times of the day? Is your sleeping area too hot or crowded? Have you had any recent illnesses? Have you experienced any unexplained weight loss, fevers or shaking chills? Are you taking any medications, large doses of vitamins, dietary or herbal supplements? Do you have difficulty sleeping or been diagnosed with a sleep disorder? Do you eat within several hours of bedtime? Do you drink alcohol or use substances of abuse? Have you recently traveled to other areas? In narrowing down the potential causes of night sweats, your physician may group the possible triggers into the following categories: Environmental (uncomfortable room temperature, poor air circulation, too many blankets, thick sheets, close proximity to a bed partner) Emotional (stress, anxiety, disturbing dreams) Hormonal (hyperthyroidism, pregnancy, perimenopause or early menopause, hypoglycemic episodes in those with or without diabetes, others) Medications including certain antidepressants, niacin (high doses), tamoxifen, leuprolide, prednisone, drugs for erectile dysfunction (flushing and warm sensation), and high blood pressure. Even medications used to fight fever (aspirin, acetaminophen) can lead to rebound sweating as their effectiveness wears off. Infections such as tuberculosis, mononucleosis, human immunodeficiency virus Medical conditions such as gastroesophageal reflux disease, obstructive sleep apnea and chronic fatigue syndrome Cancers Itching (Pruritus) Neurological concerns such as autonomic neuropathy or a delayed complication from a spinal cord injury."

Nosebleed  (not common)

Nosebleed 
(not common)

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TOPIC SEARCH: PubMed

Lymphoma can present in many ways, and the symptoms can have so many other causes.  In a support forum I wrote in response to a question: " I've never heard of nose bleeds associated with lymphoma, but I suppose it's not out of the question."  Then came two quick replies:

"My mother was also just diagnosed with NHL after recurring nosebleeds and a stuffy nose for about 6 months.   There were no other symptoms."  -   Lesli (NHL-info)

"One of the symptoms which lead to my Mother's diagnosis of NHL was reoccurring nosebleeds."   - Sandra (NHL-info)
 

Pleural effusions

Pleural effusions

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TOPIC SEARCH - PubMed

Pleural effusions, or abnormal accumulations of fluid in the pleural space around the lungs, can be caused by a wide variety of diseases, including lymphoma.  Sometimes an enlarged lymph node can block drainage of fluid that lubricates the pleural space. In such cases, successfully treating the lymphoma can resolve the condition.  To relieve symptoms and diagnose the cause, a Thoracentesis, or pleural tap may be performed.
 

	About  Medline Plus * | Emedicine | Wikipedia.org
	Thoracentesis or pleural tap (draining the fluid to relieve discomfort and diagnose cause)  Medline Plus* | meddean.luc.edu
	case report: Resolution of massive pleural effusion due to lymphoma with intrapleural interleukin-2. Elkadi D, Wiernik PH, Tong TR. http://www.ncbi.nlm.nih.gov/pubmed/20063279

Restless leg syndrome (not common)

Restless leg syndrome
(not common)

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TOPIC SEARCH: PubMed

This syndrome can make it difficult to get adequate sleep because of pain or sensations experienced in the legs while sleeping.  Restless leg syndrome might be related to an iron deficiency, which could be related to anemia.

About  NIH

Weight loss - unexplained (Cachexia)

Weight loss - unexplained (Cachexia)

Also see Diet & Exercise

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TOPIC SEARCH: PubMed | Clinical Trials 

A symptom of lymphoma progression is weight loss that cannot be explained by diet.  Cachexia, the loss of lean body mass, is most typically associated with advanced progression of the disease. 

“The formal definition of cachexia is the loss of body mass that cannot be reversed nutritionally: even if the affected patient eats more calories” wikipedia.org

Is there a difference between weight loss and wasting?
 
"Yes. As its name implies, weight loss refers to a loss of body weight. Wasting syndrome refers to a loss of body mass or size, most notably muscle mass (sometimes referred to as "lean body mass"). Very often, both occur at the same time. However, this is not always the case. It is possible that someone who is losing weight might not lose muscle mass. It is also possible that someone losing muscle mass might not lose a lot of weight."  beingalivela.org

You should report unexplained weight loss to your doctor or nurse and seek the underlying cause.

Some patients will try alternative diets that severely restrict calories.  These diets can make it difficult to determine what is causing the weight loss, and they can be potentially dangerous if they contribute to wasting.

Related articles on weight loss, cachexia, and nutrition:

	Cancer AND cachexia  Related abstracts
	Cancer Cachexia: Mechanisms and Clinical Implications PubMed "It involves multiple pathways: ...signals from tumor cells, systemic inflammation in the host, and widespread metabolic changes (increased resting energy expenditure and alterations in metabolism of protein, fat, and carbohydrate). Whether it is primarily driven by the tumor or as a result of the host response to the tumors has yet to be fully understood."
	Clinical Trials for Cachexia http://bit.ly/cmn53Y