Lymphadenopathy

Objectives Define lymphadenopathy Develop a systematic approach to the evaluation and management of lymphadenopathy Discuss the differential diagnosis of localize and generalized lymphadenopathy Recognize worrisome features of lymphadenopathy that should prompt a referral for a biopsy

Physiology & Anatomy Lymphatic system Body has 600 lymph nodes Open circulatory system Part of immune system Includes: lymph, lymphatic vessels, lymph nodes, spleen, tonsils, adenoids, Peyer patches, thymus Body has 600 lymph nodes Lymph drains through nodes as it heads to right lymphatic duct and thoracic duct

Lymphatic System

Physiology & Anatomy Lymph nodes are populated by: Macrophages, dendritic cells, B and T lymphocytes B Lymphocytes Located in follicles and perfollicular area of lymph nodes T Lymphocytes Interfollicular or paracortical area of lymph nodes

Approach to Patient Lymphadenopathy – refers to lymph nodes that are abnormal in size, number or consistency Consider: Age of Patient Size of Nodes Location of Nodes Quality of Nodes Localized or generalized Time course of the lymphadenopathy

Patient Age Not palpable in newborn Palpable nodes are the “norm” in the cervical, axillary, and inguinal regions throughout early childhood Children < 5 years old 44% palpable nodes at check up 64% palpable nodes at sick visits

Patient Age The differential diagnosis is huge! But consider age as you narrow it down. For example: Preschool and early school age: URI, AOM, Conjunctivitis Teenagers Hodgkin lymphoma STDs

Size of Lymph Nodes Rules of thumb: Axillary and cervical nodes < 1 cm Inguinal <1.5 cm Epitrochlear <0.5 cm Nodes tend to be larger in young children Odds of malignancy is higher in larger nodes especially those > 2 cm

Location of Lymph Nodes Node Groups Occipital Postauriclular Preauricular Parotid Submandibular Submental Superficial cervical Deep cervical Supraclavicular Deltopectoral Axillary Epitrochlear Inguinal Popliteal Region Drained Posterior Scalp Temporal & parietal scalp Scalp, ear canal, conjunctiva Scalp, midface, ear canal and ear, parotid Cheek, nose, lips, tongue, subman. gland Lower lip, floor of mouth Lower larynx, lower ear canal, parotid Tonsils, adenoids, scalp, larynx, sinuses Mediastinum, lungs, abdomen Arm Arm, breast, thorax, neck Medial arm below elbow Lower extremities, genitalia, abdomen Lower leg

Quality of Lymph Nodes Painful Hard Nonmobile Usually infection, especially if erythema, warmth, or fluctance Malignancy can cause node tenderness because of hemorrhage into node and stretching of capsule Hard Found in cancers because of fibrosis Nonmobile Become fixed from invasive cancers of inflammation in tissue surrounding nodes (ie TB or sarcoidosis) SOFT, COMPRESSIBLE = NORMAL

Localized vs. Generalized Lymphadenopathy Most commonly cervical then inguinal Can be infection/inflammation in the area drained by that node or infection of node itself Generalized Systemic disease

Localized Lymphadenopathy

Differential Diagnosis - Infection Bacterial Localized: Staph aureus, GAS, cat-scratch, tularemia, diphtheria Generalized : Brucellosis, leptospirosis, typhoid Viral EBV, CMV, HSV, HIV, Hep B, Measles, Mumps, Rubella, Dengue Fever Myocobacterial TB, Atypical mycobacteria Fungal Coccidiomycosis, Cryptococcosis, Histoplasmosis Protozoal Toxoplamosis, Leishmaniasis Spirochetal Lyme disease, symphilis

Differential Diagnosis - Other Malignancy leukemia, lymphoma, metastasis from solid tumor Immunologic SLE, serum sickness, Langerhans cell histiocytosis, RA, Drug Reaction, dermatomyositis, CGD Endocrine Addison disease, hypothyroidism Other Amyloidosis, Kawasaki disease, Sarcoidosis, Churg-Strauss syndrome, Kikuchi disease, Castleman disease

Time Course of Lymphadenopathy When to biopsy Many advocate biopsy of concerning nodes that have not decreased after 4-6 weeks or have not normalized in 8-12 weeks Lymph nodes present for long time are not likely to be malignant except for Hodgkins Exposure medications, animals, uncooked meats, unpasteurized milk Associated constitutional symptoms Fever, night sweats, weight loss, pruritus, arthralgias, fatigue

Specific Causes of Lymphadenopathy

Lymphadenitis Lymphadenitis – enlarged, inflamed, tender lymph nodes Organisms: Staph aureus, GAS (80%) Usually submandibular Southwest US Yersinia pestis = Bubonic plague Bartonella henselae = cat scratch TB and atypical mycobacteria (M. avium and M. scrofulaceum) 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 I&D indicated if abscess present

Infectious Mononucleosis Symptoms fever, pharyngitis, lymphadenopathy (symmetric involvement of posterior cervical nodes) EBV, CMV, toxoplasmosis, Streptococcus, hep B, HIV Testing Monospot test (heterophile antibody) High false negative in < 4 YO and early illness Specific serologic tests Elevated immunoglobulin M titer to viral capsid antigen (Igm-VCA) indicates acute infection

Diagnostic Testing to Consider Blood CBC, ESR, LDH Specific Serologic testing (EBV, CMV, Bartonella) Tuberculin Skin Testing Chest X-ray Biopsy