Lymphadenopathy Flashcards
Lymph nodes. Found generally where? Contain what? Do what?
Found throughout the body along the course of the lymphatic vessels
Lymph nodes are populated by macrophages, dendritic cells, B lymphocytes, and T lymphocytes.
Participate in antigen processing, antigen presentation, antigen recognition, and proliferation of effector B and T lymphocytes as part of the normal immune response
Lymph nodes enlargement
Proliferation of WBCs inside of lymph nodes leads to lymph node enlargement.
In young children, palpable lymphadenopathy is the rule.
In adults, lymph nodes larger than 1 to 2cm in diameter are generally considered abnormal. (except for groin, where they can be bigger normally)
2 types of lymphadeonopathy
Local lymphadenopathy reflects the area those lymph nodes drain
Generalized lymphadenopathy occur with a systemic disorders
Cervical lymphadenopathy
Anterior– usually benign
Localized strep or staph infections, rubella, dental
Systemic infections: Epstein-Barr virus (EBV), cytomegalovirus infection, or toxoplasmosis
Posterior – could be benign, but malignancy is more common than with anterior lymph nodes
EBV infection, tuberculosis, lymphoma, or head and neck malignancy
Supraclavicular
lymphadenopathy
High risk for malignancy
Right:
Cancer of mediastinum, lungs or esophagus
Left (Virchow’s node): Abdominal malignancy (stomach, gall bladder, pancreas, kidneys, testicles, ovaries, or prostate)
Axillary
lymphadenopathy
Drain arm, thoracic wall, and breast.
Infections
- Cat scratch disease
- Cellulitis
Cancer
- Breast
- Other metastasis
Silicone breast implants
( may cause both supraclavicular and axillary lymphadenopathy)
Epitrochlear
lymphadenopathy
Not normally palpable Infections of the forearm or hand Lymphoma Sarcoidosis Tularemia Secondary syphilis.
Inguinal lymphadenopathy
Lower extremity infection
Sexually transmitted diseases
Cancer
- Skin of the lower extremities and trunk
- Cervix, vulva, and ovary
- Rectum and anus
- Penis
Mediastinal.
lymphadenopathy
Infectious
- TB, fungal infection, anthrax
Neoplastic
- Lymphoma, lung cancer, germ cell tumor
Other
- Sarcoidosis
Retroperitoneal.
lymphadenopathy
Infectious
- TB
Neoplastic
- Lymphoma, testicular cancer, kidney cancer, upper GI malignancy
Other
-Sarcoidosis
Mesenteric lymphadenopathy
Infectious
- Appendicitis, cholecystitis, diverticulitis, Whipple’s disease
Neoplastic
- Lymphoma, GI cancer
Other
- Inflammatory bowel disease, panniculitis
GENERALIZED LYMPHADENOPATHY: HIV
Nontender.
Primarily axillary, cervical, and occipital nodes
Usually develops during the second week of acute symptomatic HIV infection.
The nodes then decrease in size but a modest degree of adenopathy persists.
GENERALIZED LYMPHADENOPATHY: mycobacterial infection
Can present with lymphadenopathy alone, especially in the neck (scrofula)
M. tuberculosis in adults
Atypical mycobacteria (M. avium complex and M. scrofulaceum) in kids
Nontender
Enlarge over weeks to months without prominent systemic symptoms
Can progress to matting and fluctuation
GENERALIZED LYMPHADENOPATHY Infectious Mono
Triad of fever, pharyngitis, and lymphadenopathy.
Symmetric enlargement
Posterior cervical more than anterior cervical
Axillary and inguinal are common too (as opposed to other causes of pharyngitis
Lymphadenopathy peaks in the first week and then gradually subsides over two to three weeks
GENERALIZED LYMPHADENOPATHY: other mono-like diseases
Cytomegalovirus human herpes virus 6 human immunodeficiency virus adenovirus, herpes simplex virus Streptococcus pyogenes Toxoplasma gondii
GENERALIZED LYMPHADENOPATHY: systemic lupus
In approximately 50 percent of patients
Lymph nodes are soft, nontender
Cervical, axillary, and inguinal areas
Usually develops at the onset of disease or in association with an exacerbation.
GENERALIZED LYMPHADENOPATHY: medications
Some drugs may cause serum sickness
fever, arthralgias, rash, and generalized lymphadenopathy
Phenytoincan cause generalized lymphadenopathy in the absence of a serum sickness reaction
allopurinol, atenolol, captopril, carbamazepine, cephalosporins, gold, hydralazine, penicillin, phenytoin, primidone, pyrimethamine, quinidine, sulfonamides, sulindac
zebras
not getting tested on them
but diagnosed by biopsy only
Diagnostic approach: History
Localizing signs or symptoms suggesting infection or malignancy URI symptoms Dental pain Chest pain Abdominal/pelvic pain
Exposures
Cat [cat scratch disease]
Undercooked meat [toxoplasmosis]
Tick bite [Lyme disease]
Travel (should extend the differential diagnosis to diseases)
High risk behavior (sexual behavior, injection drug use)
diagnostic approach: physical exam
Location
- Localized vs. generalized adenopathy
Size
- Greater than 1 cm in diameter.
Consistency
- Hard in cancers that induce fibrosis and when previous inflammation has left fibrosis.
- Firm, rubbery nodes in lymphomas and chronic leukemia
Fixation
- fixed to adjacent tissues by invading cancers or inflammation
Tenderness
- Suggests recent, rapid enlargement with inflammation, hemorrhage, immunologic stimulation, and malignancy.
Labs for generalized lymphadenopathy
Complete blood count, Heterophile test, and chest x-ray.
If above normal: PPD HIV antibody determination RPR ANA
Imaging
CXR US CT MRI PET
Open biopsy
The best for diagnosis
Choose the most accessible and/or biggest node
Fine needle aspiration for cytology
most useful when searching for recurrence of cancer
substantial false-negative rate due to sampling error
Used in areas where open biopsy is not available or risky
Good in patients with HIV infection for evaluating lymph nodes that are believed to harbor other disease
Spleen
Largest lymph node in the body.
Functions
Participates in the primary immune response
Acts as a filter for the blood
Responsible for removing from the circulation red blood cells, that are old, sick or if they are coated with immunoglobulins.
causes of splenomegaly
congestive (cirrhosis, heart failure, thrombosis of portal, hepatic, or splenic veins)
- infection
- infiltrative
- malignancy (Hematologic malignancies, Lymphoma, Acute and chronic leukemias, Polycythemia vera, Multiple myeloma, Essential thrombocythemia, Primary splenic tumors, Non-hematologic metastatic solid tumors)
- inflammation (Sarcoid
Serum sickness
Systemic lupus erythematosus
Rheumatoid arthritis (Felty syndrome) - hematologic
infectious causes of splenomegaly
Viral - hepatitis, infectious mononucleosis, cytomegalovirus
Bacterial - salmonella, brucella, tuberculosis
Parasitic -malaria, schistosomiasis,toxoplasmosis, leishmaniasis
Infective endocarditis (embolic)
Fungal
Hematologic (hypersplenic) states
Acute and chronic hemolytic anemias, all etiologies
Sickle cell disease (children)
Following use of recombinant human granulocyte colony-stimulatingfactor
Myelofibrosis
Symptomatology
of splenomegaly
LUQ pain
- May be acute or chronic depending on the disease
- Acute if splenic infarct or rupture present
Dizziness/hypotension with splenic rupture
Signs of the disease causing splenomegaly
- Fever, chills etc with infections
- Fatigue, weight loss with cancer
- Jaundice, ascitis with cirrhosis
spleen labs
CBC
- Neutropenia, anemia, and/or thrombocytopenia may be present without abnormal morphology (hypersplenism
- Absolute neutrophillia with or without Left shift suggest presence of splenic infarction
- Atypical lymphocytes
- Blasts/young cells
Peripheral smear
- Invading organisms (bartonellosis, babesiosis, and malaria)
- Schistocytes
- Abnormal cell morphology (spherocytes)
Infectious Mononucleosis serology
A patient with chronic alcoholism or hepatitis and ascites –
splenomegaly secondary to cirrhosis and portal hypertension.
A young adult with fatigue, fever, sore throat, and splenomegaly –
infectious mononucleosis or other viral infection.
An older adult complaining of post-bath pruritus with a ruddy complexion and splenomegaly –
polycythemia vera.
