Spleen and Lymph Nodes

Question 1

Kehr’s sign

Answer 1

aka omalgia.

LUQ TTP and pain medial to top of left shoulder joint

Question 2

Ballance’s sign

Answer 2

percussion dullness of left flank

suggest intraperitoneal bleeding.

Question 3

Hypersplenism

Answer 3

Cause: increased sequestration in spleen, increased destruction by spleen, Ab in spleen causing this.
Features: cytopenia (anemia, leukopenia, thrombocytopenia), normal or hyperplastic cellular precursors in bone marrow

Question 4

Hemolytic anemia

Answer 4

1.membrane structural abnormalities
a. hereditary spherocytosis
2.metabolic abnormalities
a. pyruvate kinase deficiency
b. G6PD deficiency
not cured by splenectomy
3. hemoglobinopathies
a. sickle cell disease
b. thalassemias

Question 5

Hereditary spherocytosis

Answer 5

AD
Cause: deficiency in membrane proteins for deformability (spectrin, ankyrin, band 3).
Features: abnormally shaped, rigid red cells, may present with symptomatic cholelithiasis (black stones), hemolytic episodes, aplastic crisis
Tx: splenectomy

Question 6

Sickle Cell Disease

Answer 6

AR
valine substituted for glutamic acid in beta chain of hemoglobin A.
Dx: sickled cells at low O2
Tx: splenectomy early but can autoinfarct

Question 7

Thalassemias

Answer 7

cause: deficits in one or more component of hemoglobin
Major: homozygous beta-thalassemia
Tx: splenectomy if high risk for OPSI

Question 8

Acquired Autoimmune Hemolytic Anemia

Answer 8

Coomb’s negative = from drugs, toxins, infectious agents
Tx: steroids, remove agent
Coomb’s pos = autoimmune
Tx: steroids, treat underlying cause

Question 9

Immune Thrombocytopenic Purpura (ITP)

Answer 9

acute = usually after viral infection, good prognosis
chronic = in young adults F>M
Features: petechia and purpura, antiplatelet Ab
Tx: steroids, gamma globulin or monoclonal antibody, splenectomy

Question 10

Thrombotic Thrombocytopenic Purpura (TTP)

Answer 10

disease of arteries and capillaries
Features: thrombotic episodes and low platelet counts, fever, purpura, hemolytic anemia, neurologic manifestations, renal disease.
Tx: plasma pheresis with or without antiplatelet therapy, whole blood exchange, steroids. splenectomy as last resort

Question 11

HIV-associated Thrombocytopenia

Answer 11

Tx: splenectomy

Question 12

Diseases associated with Hypersplensism

Answer 12

congestive diseases of spleen
portal HTN
splenic vein thrombosis
infiltrative diseases of spleen
Gaucher’s disease, Niemann Pick disease, amyloidosis, extramedullary hematopoiesis
leukemia, lymphoma, Hodgkin’s disease, tumors
Felly’s syndrome (RA, splenomegaly, neutropenia)
Porphyria erythropoietica
sarcoidosis
Tx: splenectomy if platelets <2,000 with or without infection, or need blood transfusion

Question 13

Infections in Postsplenectomy Patients

Answer 13

Strep pneumo
HiB
N. meningitidis
beta hemolytic strep
staph aureus
E choli
pseudomonas

herpes zoster

babesiosis
malaria

Question 14

Posterior auricular lymphadenopathy

Answer 14

from rubella

Question 15

Anterior auricular lymphadenopathy

Answer 15

from conjunctival or eyelid infections

Question 16

Posterior cervical lymphadenopathy

Answer 16

toxoplasmosis
metastatic cancer
lymphoma
TB

Question 17

Submental lymphadenopathy

Answer 17

dental infection

Question 18

Anterior cervical lymphadenopathy

Answer 18

oral cavity/pharyngeal infection
met squamous cell cancer
lymphoma
TB

Question 19

Axillary lymphadenopathy

Answer 19

cat scratch disease
breast cancer
lymphoma
upper extremity infection

Question 20

Epitrochlear lymphadenopathy

Answer 20

handinfection
viral disease in kids
sarcoidosis
tularemia

Question 21

inguinal lymphadenopathy

Answer 21

lower extremity infection
lympohgranuloma venereum
gonorrhea
herpes
lymphoma
met rectal cancer

Question 22

Pulmonary hilar lymphadenopathy

Answer 22

met lung cancer
sarcoidosis
TB
histoplasmosis
coccidiodomycosis

Question 23

Mediastinal lymphadenopathy

Answer 23

Hodgkin’s lymphoma
sarcoidosis
met cancer

Question 24

Generalized lymphadenopathy

Answer 24

infections: influenza, IM, rubella, TB, CMV

systemic disease: HIV, sarcoidosis, Addison’s disease, hyperthyroidism, hypopituitarism, leukemia, lymphoma

drugs: allopurinol, atenolol, captopril, carbamazepine, cephalosporins, gold, hydralazine, penicillin, phenytoin, primidone, pyrimethamine, quinidine, sulfonamides, sulindac

Question 25

Supraclavicular lymphadenopathy

Answer 25

cancer

Question 26

Hodgkin’s Lymphoma

Answer 26

ages: late 20’s or mid 70’s
may involve EBV and monocyte macrophage cell line
Features: cervical lymphadenopathy, supradiaphragmatic disease in young, fever, night sweats, weight loss
Dx: CXR, excisional biopsy, bone marrow biopsy, CT
Categories:
1. nodular lymphocyte predominate
2. lymphocyte rich
3. nodular sclerosis
most common
4. mixed cellularity
5. lymphocyte depleted
Histology: have Reed-Sternberg cells = owl’s eye, multinuclear giant cells
also present in IM and with phenytoin use.
stage A = asymptomatic
stage B = sypmtomatic = fever, night sweats, weight loss
Tx: stages 1-2 = radiation therapy
stages 3 and above = chemotherapy with nitrogen mustard, vincristine, procarbazine, prednisione, or doxorubicin, bleomycin, vinblastine, and dacarbazine

Question 27

Non Hodgkin’s Lymphoma

Answer 27

associated with HIV, organ transplantation
EBV => Burkitt’s lymphoma
human T cell lymphoma virus 1 => Tcell lymphoma in Caribbean Islands
Features: enlarged lymph nodes, N/V, bleeding.
can present with SVC syndrome, acute spinal cord compression, MALT lymphoma, meningeal involvement
Dx: CBC, LFT, CXR, CT chest abd pelvis, bone marrow biopsy
Tx: surgery, radiation, chemotherapy*