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

2. 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)

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

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

5. 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

6. 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

7. 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)

8. 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)

9. 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

10. 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.

11. 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

12. 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.

13. 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.)

14. Specific Causes of Lymphadenopathy

15. 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)

16. 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

17. 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

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

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