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Approach to a Patient with Lymphadenopathy

Approach to a Patient with Lymphadenopathy. Lymphadenopathy. Enlargement of the lymph nodes. Can be considered normal: 1) soft, flat, submandibular nodes (<1cm) in healthy children and young adults; 2) palpabale inguinal lymph nodes of up to 2cm in diameter in healthy adults.

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Approach to a Patient with Lymphadenopathy

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  1. Approach to a Patient with Lymphadenopathy

  2. Lymphadenopathy • Enlargement of the lymph nodes. • Can be considered normal: 1) soft, flat, submandibular nodes (<1cm) in healthy children and young adults; 2) palpabale inguinal lymph nodes of up to 2cm in diameter in healthy adults. • May be a primary or secondary manifestation of numerous disorders, both benign and malignant.

  3. Clinical Assessment • Medical History • Physical Examination • Laboratory Tests • Excisional LN Biopsy

  4. Medical History • Reveals the setting in which lymphadenopathy is occuring. • General information, accompanying symptoms, personal and social history. • Ex.: viral/bacterial URTI, toxoplasmosis, TB benign disorders in children and young adults; if>50 y/o increase incidence of malignant disorder.

  5. Physical Examination • Extent of lymphadenopathy ( localized or generalized), size, texture, presence/ absence of tenderness, signs of inflammation over the node, skin lesions, and splenomegaly. • ENT exam indicated in an adult patient with cervical lymphanedopathy with history of tobacco use.

  6. Extent of Lymphadenopathy • Localized/regional- involvement of a single anatomic site. • Generalized- involvement of 3 or more non-contiguous lymph node areas; usually indicates non- malignant disorder (except for ALL, CLL, and malignant lymphomas.)

  7. Site of Localized Adenopathy • Occipital • Preauricular • Neck • Supraclavicular and scalene • Virchow’s nodes • Axillary • Inguinal

  8. Size of the Node • <1.0 cm2 –benign; non-specific causes. • >2.0 cm/ >2.25cm2 -malignant or granulomatous disease.

  9. Texture and Presence of Pain • Acute leukemia- pain in nodes due to rapid enlargement. • Lymphoma- large, discrete, symmetric, rubbery, firm, and non-tender. • Metastatic cancer- hard, non-tender, and non moveable. • W/ splenomegaly- systemic illness (IM, lymphoma, acute or chronic leukemia, etc.)

  10. Thoracic Adenopathy • Detected by CXR or work-up for superficial adenopathy. • May cause coughing/wheezing, hoarseness, dysphagia, and/or swelling of the face and neck. • Due to a primary lung disorder or systemic illness.

  11. Abdominal and Retroperitoneal Adenopathy • Usually malignant. • TB mesenteric lymphadenitis; lymphoma; GCT in young men.

  12. Laboratory Investigation • CBC • Serology • CXR • CT and MRI • Ultrasound

  13. Lymph Node Biopsy • Done if PE findings suggest malignancy. • Biopsy evident primary lesion first. • FNAB- not to be used as primary diagnostic procedure; for thyroid nodules or confirmation of relapse in patient whose primary diagnosis is known. • Guidelines: Older patients (>40y/o), large LN (>2.25cm2 ), hard and non-tender

  14. Follow-up and Treatment • Follow-up at 2-4 weeks interval for benign causes. • Antibiotics are given only if there is strong evidence of bacterial infection. • 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 IM.)

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