DR.FAROOQ ALAM M.B.B.S-M.phil Lymphadenopathy DR.FAROOQ ALAM M.B.B.S-M.phil

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 >1.0 cm in greatest diameter Certain nodes should be considered enlarged at different sizes (i.e. epitrochlear nodes > 0.5 cm, inguinal nodes > 1.5 cm, submandibular nodes > 1.5 cm)

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

Etiology of Lymphadenopathy Acute Infectious Subacute/Chronic Infectious Malignancy Systemic disease/Non-infectious

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

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

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)

Immunizations Smallpox (historically) Live attenuated MMR(Measles,Mums,Rubella),(Diptheria,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)

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

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.

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

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.

DO NOT USE GLUCOCORTICOIDS-might obscure diagnosis or delay healing in cases of infection (EXCEPTION: life-threatening pharyngeal obstruction by enlarged lymph tissue in Waldeyer’s ring caused by Infectious mononucleosis( IM.)

Specific Causes of Lymphadenopathy

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)

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

Suppurative Bacterial Lymphadenitis Staphylococcus aureus and Group A Streptococcus 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 I&D vs Surgical Excision if abscess is identified

Cat Scratch Disease Species involved: Bartonella Henselae Antibiotics always given to immunocompromised patients to prevent disseminated disease

Toxoplasmosis Toxoplasma gondii: 90% have cervical lymphadenitis Treatment with pyrimethamine or sulfonamides