Lymphadenopathy and Splenomegaly Flashcards
More than 2/3 if patients with LAD have what?
URI (Viral or bacterial) and
<1% have malignancy
Ddx of Anterior cervical LAD
Infections: EBV, CMV, toxoplasma
Malignancy: Lymphoma, CLL, head/neck cancer
Ddx of Posterior cervical LAD
Infection: TB***, EBV
Malignancy: Lymphoma, CLL, head/neck cancer
What age should you start to take into consideration malignant causes of LAD?
> 50YO
Ddx of generalized LAD
Cause is most often non-malignant and systemic disease.
- HIV
- CMV
- Other viral (esp infectious mono/EBV)
- Inflammatory disorders (SLE)
- Toxoplasmosis
Other: acute/chronic lymphocytic leukemia and lymphoma.
What is important to note if a patient presents with Supraclavicular LAD?
HIGH RISK AREA FOR MALIGNANCY (35-50%).
Risk INC >40YO.
Right Supraclavicular LAD
Cancer in mediastinum, lung and esophagus
Virchows node (L Supraclavicular LAD)
Metastatic cancer from GI
Enlarged ______ and _____ is ALWAYS abnormal.
- Supraclavicular
2. Scalene
Axillary LAD
Usually due to injuries/localized infection of ipsilateral UE.
Infection: Cat Scratch Disease
Malignancy: Skin/breast cancer
Inflammation: Silicone breast implants
Palpable Epitrochlear LN is always ____
Pathologic
Epitrochlear LAD
Infection: Infection of forearm/hand, tularemia, Strep, Cat scratch disease, 2’ syphillis ***
Inflammation: sarcoid
Malignancy: lymphoma (rare)
Inguinal LAD
Infection: LE infection, STD
Malignancy: lymphoma, skin cancer, GU, anus/rectal cancer
Sister Mary Joseph Node/Nodule *
Prognosis of this?
Palpable nodule in the BB (not a true LN) that represents metastasis from intraabdominal/intrapelvic cancer..
Most often, GI cancer, but in women 25% are GYN cancer.
Bad prognostic sign.
You will look like a rockstar if you a patient presents with Cervical LAD and your Ddx is…
- Infections
- Lymphoma
- Uncommon disorders (Kikuchi, TB)
Nodes ____cm2 are almost alway due to benign, nonspecific reactive causes.
When should these patients be under observation?
< 1cm2
ABNL LN are generally greater than 1cm.
Observe after excluding infectious mono or toxoplasmosis, unless sx and signs of underlying systemic illness.
Ddx for tender LN
Usually inflammatory process.
Malignancies: acute leukemia
Describe the LN in lymphomas/chronic leukemia
How is this different from LN in Acute Leukemias?
Large, discrete, symmetric, rubbery, firm, mobile and non-tender
In Acute Leukemias, LN tend to be softer.
Describe the LN in metastatic cancers
Hard, non-tender, non-moveable
LAD + splenomegaly suggests
Systemic illness:
- Infectious mono
- Lymphoma
- CLL/acute leukemia
Ddx Mediastinal/Hilar adenopathy in young patients
Infectious mono
Sarcoidosis
In endemic regions, histoplasmosis can cause ______
Unilateral paratracheal LAD, which mimics lymphoma.
Enlarged intra-abdominal or retroperitoneal LN are usually _______
Malignant
_____ infection is associated with undercooked meat
Toxoplasmosis
LAD + constitutional symptoms (fever, night sweats, WL) suggest what?
- TB
2. Lymphoma or other cancers
Fever usually accompanies LAD in a majority of _____ etiologies
Infectious. Thus, no fever may mean cancer.
“Shotty LN” =
Multiple, small LN, with no diagnostic significance
Ddx for hard LN
Cancers that cause fibrosis or previous inflammation that has caused fibrosis.
Ddx for fixed LN
Invading cancers or inflammation in tissue surrounding nodes
What is the diagnostic approach to a patient with Generalized LAD (involvement of 3 or more noncontiguous LN)?
- CBC + CXR
If NL, - PPD
- HIV
- RPR
- ANA
- Serology for EBV and CMV
CBC is useful for diagnosing…
- Acute/chronic Leukemia,
2. EBV/CMV
Serology is useful for diagnosing
- EBV/CMV/HIV
2. Toxoplasma gondii
What imaging studies are useful to diagnose metastases to the cervical LN?
CT and MRI
Prompt biopsy of a LN should be done when?
H&P suggest cancer.
Primary head or neck cancer is suspected based on the a solitary, hard cervical LN.
What should be done?
ENT exam
Most LAD do NOT require what?
Biopsy and labs
If H&P suggests a benign cause of LAD, what should be done?
2-4 week F/U.
PEARL: What are B-symptoms and what do they suggest?
- Fever
- Nigh sweats
- WL >10% in 6 months
Suggest a paraneoplastic syndrome or worse prognosis of HL/NHL (DLBL or Burkitt)
What is the only time glucocorticoids should be used to treat LAD?
When enlarged lymphoid tissue in Waldeyers ring causes life-threatening pharyngeal obstruction, commonly seen in infectious mono.
PEARL: Immunocompromised patients are at increased risk for what?
Primary CNS lymphoma
Patient presents with LUQ pain and heavy sensation + early satiety. This suggests…
Splenomegaly
What imaging tool is used for routine assessment of the size of the spleen?
Ultrasound: high sensitivity and specificity
What are the 3 mechanisms for splenomegaly?
- Hyperplasia/hypertrophy
- Passive congestion due to decreased BF
- Infiltrative diseases
What conditions can cause hyperplasia/hypertrophy of spleen?
Disorders that require removal of large number of RBC:
- Hereditary spherocytosis
- Thalassemia
Immune hyperplasia due to systemic infection
- Infectious mono, subacute bacterial endocarditis
- AI
What conditions can cause passive congestion of spleen?
Conditions that cause portal HTN
- Cirrhosis
- Budd Chiari
- CHF
What are infiltrative diseases of the spleen?
- Lymphoma
- Metastatic cancers
- Myeloproliferative diseases
Ddx for a “massively enlarged spleen” (palpable, >8cm, >1000g)
Massively enlarged spleens have fewer Ddx
- NHL
- CLL
- Hairy cell leukemia
- CML
- MYelofibrosis
- Polycythemia vera
Splenomegaly + decreased granulocyte counts
- Felty syndrome
- Congestive splenomegaly
- Leukemia
Splenomegaly + decreased platelet counts
- Sequestration
2. Destruction of platelets (congestive splenomegaly, Gaucher, immune thrombocytopenia)
Splenomegaly + increased platelet counts
- Myeloproliferative disorders (polycythemia vera)
Splenomegaly + CBC that suggests cytopenias is characterized by what?
Splenomegaly
Cytopenias
NL or hyperplastic BM
Response to splenectomy.
