1. LENFADENOPATHY

2. DEFINITION
abnormality of the lymph nodes in terms of number, hardness, and volume

3. LAP
Generalized LAP:
two or more seperate lymph node group are effected.
Localized LAP:
one or more lymph nodes in the same region are effected

5. Epidemiology Rece is not a major criteria. Sex: M/F=1
Age: most frequent in younger children, less frequent in newborn.

6. Pathophsiology
Increase in the number of benign lymphocytes and macrophages in the process of response to antigens
Infiltration of the lymph nodes with the inflammatory cells during infection
Infiltration of the lymph nodes with metastatic malignant cells
In situ proliferation of lymphocytes and macrophages
Infiltration of the lymph nodes with metabolite-laden macrophages during storage diseases

7. I. Generalized Lenfadenopahy
A- Infection
B- Neoplastic ve proliferative disorders
C- Storage diseases
D- Autoimmune disorders and hypersensitivity reactions

8. A- Infections
1- Viral:
- Generalized upper respiratort tract infections
- Infectious mononucleosis
- CMV
- AIDS
- chickenpox
- measles

9. A- Infections
2-Bacterial
- Septisemia
- Typhoid fever
- Tb
- Syphilis

10. A- Infections
3- Protozoal - Toxoplazmosis
4- Fungal - Coccidiomycosis

11. B- Neoplastic and Proliferative Disorders
Acute leukemia
Lymphomas (Hodgkin, non-Hodgkin)
Neuroblastoma
Histiocytosis

12. C- Storage diseases
Gaucher
Niemann-Pick

13. D- Otoimmune disorders and Hypersensitivity reactions
Juvenile rhomatoid arthritis (JRA)
Systemic lupus erythematosus
Drug reactions (eg: fenitoin, allopurinol)
Serum sickness

14. 2- Localized lymphadenopathy
Cervical
Submaxillary and submental
Occipital
Preauricular
Mediastinal
Supraclavicular
Axillary
Abdominal
Inguinal

15. Cervical Viral URTI IM Rubella Cat scratch disease
Streptococcal pharyngitis
Acute bacterial lymphadenitis
Toxoplasmosis
Tb/atypical mycobacterial infection
Acute leukemia
Lymphoma
Neuroblastoma
Rhabdomyosarcoma
Kawasaki disease
Nasopharynx carcinoma

16. Submaxillary and submental
Oral and dental infections
Acute lymphadenitis

18. Occipital Pediculosis capitis Tinea capitis
Secondary to local skin infections
Rubella

19. Preauricular Local skin infections chronic ophtalmic infections
Cat-scratch disease

20. Mediastinal ALL Lymphoma Sarkoidosis Cystic fibrosis Tb Histoplasmosis
Coccidiomycosis

21. Supraclavicular
Lymphoma Tb
Histoplasmosis
Coccidiomycosis

23. Abdominal
Acute mesenteric adenitis
Lymphoma

24. Inguinal Local infection Diaper dermatitis Insect bite Syphilis
Lenfogranuloma venerum

25. Approach to a patient with LAP

26. criteria for LAP differs in pediatric age group.
small, hard, a few mm in diameter
bilateral ant. cervical
Axillary
Inguinal
Occipital
Normal
< 2 cm.
< 1 cm.
< 1.5 cm.

27. LAP in newborn is always abnormal
Lymph nodes >10 mm are considered enlarged
Epitrochlear
Inguinal
Posterior auricular, epitrochlear and supraclavicular
Abnormal
even 5 mm.
> 15 mm.

28. History and PE History: Duration
Accompanying condition: eg: contact with cats,rodent bite, tick bite, tonsillitis, skin lesions etc…
Symptoms (fever, weight loss, night sweats)
Medications: fenitoin, cephalosporins,sulphonamids…
Travel history

29. Physical examination:
Localization:
tonsillar and inguinal lymph nodes: secondary to localized infections
Supraclavicular (SC) and axillary lymph nodes (even if<0.5 cm. ) warrant further investigation
left SC: intraabdominal malignancy
right SC: thoracic malignancy

30. size: character: Symptoms:
hard,rubbery ones without tenderness and redness suggest malignancy. Occasionally rapid growing malignant lymph node may be tender
Warm, tender and fluctuant lymph nodes suggest infection or inflammation (lymphadenitis)
Symptoms:
Localized pain
tenderness
redness

31. Dysphagia and respiratory difficulty occur as a result of abscess formation of the retropharyngeal nodes.
cyanosis, dyspnea, stridor, cough, fascial edema suggest mediastinal LAP
Abdominal pain suggests mesenteric and retroperitoneal LAP

32. Work-up for localized or generalized LAP
Thorough history of infection, contact with rodents or cats and systemic complaints
Physical examination for evidence of hematologic disease, such as hepatosplenomegaly and petechiae)
Blood count and, ESR
Skin tests (Tb, Cat scratch disease, fungal infections)
Cultures (from the regional lesions  throat etc.
Serologic tests (Toxoplazmozis, CMV,EBV,HIV..etc)

33. Chest radiograph and CT scan (if necessary); abdominal sonogram and CT, if indicated
Ultrasonography is useful in an acute setting in assessing whether a swelling is nodal in origin, an infected cyst or other soft tissue mass. It may detect an abscess requiring drainage
Lymph node aspiration and culture; helpful in isolating the causative organism and deciding on an appropriate antibiotic when infection is the cause of the lymphadenopathy
Fine needle aspiration; may yield a definite or preliminary cytologic diagnosis andoccasionally obviate the need for lymph node biopsy; it provides limited material in the event flow cytometry is required and negative results cannot rule out a malignancy because the sample may be inadequate
Bone marrow examination if leukemia or lymphoma is suspected
Lymph node biopsy

35. Indications for lymph node biopsy
Lymph node biopsy is indicated if:
• Initial physical examination and history suggest malignancy
• Lymph node size is greater than 2.5 cm in absence of signs of infection
• Lymph node persists or enlarges
• Appropriate antibiotics fail to shrink node within 2 weeks
• Supraclavicular adenopathy.

36. Following precautions should be observed during Bx
Upper cervical and inguinal areas should be avoided; lower cervical and axillary nodes are more likely to give reliable information
The largest node should be biopsied, not the most accessible one. The oncologist should select the node to be biopsied in consultation with the surgeon
The node should be removed intact with the capsule, not piecemeal
The lymph node should be immediately submitted to the pathologist fresh or in sufficient tissue culture medium.
The node must not be left in strong light
it should not be wrapped in dry gauze.
Fresh and frozen samples should be set aside for additional studies

37. What to do with the biopsy
1-culture: bacterial,viral,fungal and gram staining
2-viral studies
3-histologic examination
4-light and electron microscopy
5-immunohystochemical staning: in order to differenciate the tumor type
6-flow cytometry: to decide upon the type of leukemia or lymphoma
7-genetic investigations