1. Lymphadenopathy

2. 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

3. 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

4. Lymphatic System

5. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Localized Lymphadenopathy

15. 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

16. 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

17. 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

18. Specific Causes of Lymphadenopathy

19. 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

20. 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

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