1. Lymphadenopathy M.JARI.MD.

2. Objectives Define lymphadenopathy Develop a systematic approach to the evaluation and management of lymphadenopathy Discuss the differential diagnosis of localize and generalized lymphadenopathy

3. Lymphatic System

4. Lymphtic system Lymph nodes Lymphatic Vessels Spleen Thymus Adenoid Tonsils

5. Lymphatic capillaries: L.capillaries are in all organs except : Brain Heart Epiderm Nails

6. Physiology & Anatomy Lymph nodes are populated by:  dendritic cells, B and T lymphocytes,macrophage  B Lymphocytes  T Lymphocytes

8. 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

9. 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

10. 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

11. Quality of Lymph Nodes Painful  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

12. Localized Lymphadenopathy

13. 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

14. 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

15. 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

16. 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  1 st /2 nd generation cephalosporin or dicloxacillin  Clindamycin or Augmentin if anaerobe suspected (oral)  Ultrasound to determine if abscess  I&D indicated if abscess present

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