Lymphadenopathy

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Lymphadenopathy
DR.FAROOQ ALAMM.B.B.S-M.Phil
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Definition

• Palpable lymph nodes are normal in anterior
  cervical, axillary and inguinal regions in
  healthy person.
• Lymphadenopathy is enlargement of the lymph nodes
  beyond this normal state. Practically this is any
  node gt1.0 cm in greatest diameter
• Certain nodes should be considered enlarged at
  different sizes (i.e. epitrochlear nodes gt 0.5
  cm, inguinal nodes gt 1.5 cm, submandibular nodes
  gt 1.5 cm)

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• Generalized adenopathy has been defined as
• involvement of three or more
  noncontiguous lymph node areas.
• generalized lymphadenopathy is
  frequently associated with
  nonmalignant disorders

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History

• Duration
• Short (lt 2 weeks) - likely to be infectious
• Long (gt 2 weeks but lt 1 year) - likely to be
  infectious, malignancy, autoimmune, drug reaction
  
• Very long (gt 1 year) likely to be pathologic but
  not malignancy

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Cont. History

• Location
• Localized - likely to be infectious
• Regional - likely to be infectious
• Head and Neck - likely infectious
• Inguinal - likely infectious
• Mediastinal - likely pathologic
• Abdominal - likely pathologic
• Generalized - more likely pathologic (e.g.
  malignancy, autoimmune, etc.)

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Other history

• Pets - especially cats for Cat Scratch Disease
• Travel - including Tuberculosis exposure
• Possible immunodeficiency risk such as HIV
• Family history of similar problems
• Previous treatments (such as antibiotics and how
  patient responded)

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Etiology of Lymphadenopathy

• Acute Infectious
• Subacute/Chronic Infectious
• Malignancy
• Systemic disease/Non-infectious

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Differential Diagnosis of Generalized
Lymphadenopathy

• Infectious
• Bacterial - Staphylococcus, Streptococcus, Cat
  Scratch Disease, Toxoplasmosis, Syphilis,
  Tuberculosis, Atypical mycobacterium,
  Brucellosis, Tularemia, Leptospirosis
• Viral - Epstein Barr Virus, Cytomegalovirus, HIV,
  Rubella, Hepatitis B
• Fungal - Aspergillosis, Candida, Histoplasmosis

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Cont. Differential Diagnosis of Generalized
Lymphadenopathy

• Malignant - Leukemia, Lymphoma, Metastatic
• Autoimmune - Rheumatoid arthritis, Systemic Lupus
  Erythematosis, Serum Sickness, Sarcoidosis
• Immunodeficiency HIV
• Other benign/pathologic processes - Storage
  diseases, Embryological cysts

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Medications That May Cause Lymphadenopathy

• Allopurinol (Zyloprim) Atenolol (Tenormin)
  Captopril (Capozide) Carbamazepine (Tegretol)
  Cephalosporins Gold Hydralazine (Apresoline)

• Penicillin Phenytoin (Dilantin) Primidone
  (Mysoline) Pyrimethamine (Daraprim) Quinidine
  Sulfonamides Sulindac (Clinoril)

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• Immunizations
• Smallpox (historically)
• Live attenuated MMR(Measles,Mums,Rubella),(Dipther
  ia,Polio,Tetanus)- DPT
• Poliomyelitis
• Typhoid fever
• Usually self limited and resolves with
  cessation of medication or with time in the case
  of immunization induced LAD(Lymph adenopathy
  disease)

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Approach to Lymphadenopathy
No
Reassure Family
Lymphadenopathy
Yes
Yes
Significant Physical Signs or Symptoms? e.g.
Weight loss, Hepatosplenomegaly
No
Node(s) Increase in size Not Resolving
Observe 2-3 Weeks
Node(s) Resolving
Investigate (CBC, ESR )
Observe Follow
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Follow-up and Treatment

• There is no specific treatment of swollen lymph
  nodes.Generally the underlying cause needs to be
  treated,which may result in the resolution of the
  swollen lymph node.So first Identify underlying
  cause and treat as appropriate confirmatory
  tests. If the patient have a known illness that
  causes lymphadenopathy?Treat and monitor for
  resolution.

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Follow-up and Treatment

• Generalized adenopathy usually has identifiable
  cause.
• Localized adenopathy . Is there an obvious
  infection to explain the lymphadenopathy (e.g.,
  infectious mononucleosis)?Treat and monitor for
  resolution.
• 3-4 week observation period for benign causes.If
  resolution not occur then high clinical
  suspicion for malignancy
• Biopsy if risk for malignancy - excisional

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Antibiotics are given only if there is strong
evidence of an Infections.Antibiotic therapy is
indicated to rapidly decrease node size within
the first 30 days. Antibiotic therapy should be
considered in all patients, especially those who
are immuno-compromised and at increased risk for
disseminated disease.
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• DO NOT USE GLUCOCORTICOIDS-might obscure
  diagnosis or delay healing in cases of infection
  (EXCEPTION life-threatening pharyngeal
  obstruction by enlarged lymph tissue in
  Waldeyers ring caused by Infectious
  mononucleosis( IM.)

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Specific Causes of Lymphadenopathy
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Lymphadenitis

• Lymphadenitis enlarged, inflamed, tender lymph
  nodes
• Organisms
• Staph aureus, GAS (80)
• Usually submandibular
• Southwest US
• Yersinia pestis(Gram negative rod shape
  coccobacillus) Bubonic plague(OTHER 2 VARIETY
  ARE PNEUMONIC SEPTICEMIC)
• Bartonella henselae cat scratch
• TB and atypical mycobacteria (M. avium and M.
  scrofulaceum)

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• Management
• Culture drainage or of pharyngeal exudate
• Treatment
• 1st/2nd generation cephalosporin or dicloxacillin
• Clindamycin or Augmentin if anaerobe suspected
  (oral)
• Ultrasound to determine if abscess
• ID indicated if abscess present

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Suppurative Bacterial Lymphadenitis

• Staphylococcus aureus and Group A Streptococcus
• Common history reveals recent
• URI
• Earache
• Sore Throat/Toothache
• Skin Lesions
• Management is initially with oral or IV
  antibiotics depending on severity of infection
• If not resolving or getting worse
• CT with contrast and/or Ultrasound to evaluate
  for phlegmon/abscess/infiltrate
• FNA vs Surgical ID vs Surgical Excision if
  abscess is identified

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Cat Scratch Disease

• Species involved
• Bartonella Henselae
• Age lt20, MgtF,
• 90 have had exposure to cat bite or scratch
• Can take up to 2 weeks to develop
• Antibiotics always given to immunocompromised
  patients to prevent disseminated disease
• Other less common zoonotic causes are
  tularemia, brucellosis, and anthracosis.

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Toxoplasmosis

• Toxoplasma gondii
• Mechanism
• Consumption of undercooked meat
• Ingestion of oocytes from cat feces
• Symptoms
• Malaise, fever, sore throat, myalgias
• 90 have cervical lymphadenitis
• Diagnosis by serologic testing

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• Complications include
• myocarditis
• pneumonitis
• Risk of TORCH(a group of congenitally infections
  causes a syndrome characterized by
  microcephaly,sensoneural deafness,chorioretinitis,
  hepatospleenomegaly thrombocytopenia) infection
  to fetus.
• Treatment with pyrimethamine or sulfonamides