Lymphadenopathy

1. Lymphadenopathy

2. Objectives • Define lymphadenopathy • Develop a systematic approach to the evaluation and management of lymphadenopathy • Discuss the differential diagnosis of localize and generalized lymphadenopathy • Recognize worrisome features of lymphadenopathy that should prompt a referral for a biopsy

3. Physiology & Anatomy • Lymphatic system • Open circulatory system • Part of immune system • Includes: lymph, lymphatic vessels, lymph nodes, spleen, tonsils, adenoids, Peyer patches, thymus • Body has 600 lymph nodes • Lymph drains through nodes as it heads to right lymphatic duct and thoracic duct

4. Lymphatic System

5. Physiology & Anatomy • Lymph nodes are populated by: • Macrophages, dendritic cells, B and T lymphocytes • B Lymphocytes • Located in follicles and perfollicular area of lymph nodes • T Lymphocytes • Interfollicular or paracortical area of lymph nodes

7. Approach to Patient • Lymphadenopathy – refers to lymph nodes that are abnormal in size, number or consistency • Consider: • Age of Patient • Size of Nodes • Location of Nodes • Quality of Nodes • Localized or generalized • Time course of the lymphadenopathy

8. Patient Age • Not palpable in newborn • Palpable nodes are the “norm” in the cervical, axillary, and inguinal regions throughout early childhood • Children < 5 years old • 44% palpable nodes at check up • 64% palpable nodes at sick visits

9. Patient Age • The differential diagnosis is huge! But consider age as you narrow it down. For example: • Preschool and early school age: • URI, AOM, Conjunctivitis • Teenagers • Hodgkin lymphoma • STDs

10. Size of Lymph Nodes • Rules of thumb: • Axillary and cervical nodes < 1 cm • Inguinal <1.5 cm • Epitrochlear <0.5 cm • Nodes tend to be larger in young children • Odds of malignancy is higher in larger nodes especially those > 2 cm

11. Node Groups Occipital Postauriclular Preauricular Parotid Submandibular Submental Superficial cervical Deep cervical Supraclavicular Deltopectoral Axillary Epitrochlear Inguinal Popliteal Region Drained Posterior Scalp Temporal & parietal scalp Scalp, ear canal, conjunctiva Scalp, midface, ear canal and ear, parotid Cheek, nose, lips, tongue, subman. gland Lower lip, floor of mouth Lower larynx, lower ear canal, parotid Tonsils, adenoids, scalp, larynx, sinuses Mediastinum, lungs, abdomen Arm Arm, breast, thorax, neck Medial arm below elbow Lower extremities, genitalia, abdomen Lower leg Location of Lymph Nodes

12. Quality of Lymph Nodes • Painful • Usually infection, especially if erythema, warmth, or fluctance • Malignancy can cause node tenderness because of hemorrhage into node and stretching of capsule • Hard • Found in cancers because of fibrosis • Nonmobile • Become fixed from invasive cancers of inflammation in tissue surrounding nodes (ie TB or sarcoidosis) • SOFT, COMPRESSIBLE = NORMAL

13. Localized vs. Generalized Lymphadenopathy • Localized • Most commonly cervical then inguinal • Can be infection/inflammation in the area drained by that node or infection of node itself • Generalized • Systemic disease

14. Localized Lymphadenopathy

15. Differential Diagnosis - Infection • Bacterial • Localized: Staph aureus, GAS, cat-scratch, tularemia, diphtheria • Generalized : Brucellosis, leptospirosis, typhoid • Viral • EBV, CMV, HSV, HIV, Hep B, Measles, Mumps, Rubella, Dengue Fever • Myocobacterial • TB, Atypical mycobacteria • Fungal • Coccidiomycosis, Cryptococcosis, Histoplasmosis • Protozoal • Toxoplamosis, Leishmaniasis • Spirochetal • Lyme disease, symphilis

16. Differential Diagnosis - Other • Malignancy • leukemia, lymphoma, metastasis from solid tumor • Immunologic • SLE, serum sickness, Langerhans cell histiocytosis, RA, Drug Reaction, dermatomyositis, CGD • Endocrine • Addison disease, hypothyroidism • Other • Amyloidosis, Kawasaki disease, Sarcoidosis, Churg-Strauss syndrome, Kikuchi disease, Castleman disease

17. Time Course of Lymphadenopathy • When to biopsy • Many advocate biopsy of concerning nodes that have not decreased after 4-6 weeks or have not normalized in 8-12 weeks • Lymph nodes present for long time are not likely to be malignant except for Hodgkins • Exposure • medications, animals, uncooked meats, unpasteurized milk • Associated constitutional symptoms • Fever, night sweats, weight loss, pruritus, arthralgias, fatigue

18. Specific Causes of Lymphadenopathy

19. Lymphadenitis • Lymphadenitis – enlarged, inflamed, tender lymph nodes • Organisms: • Staph aureus, GAS (80%) • Usually submandibular • Southwest US • Yersinia pestis = Bubonic plague • Bartonella henselae = cat scratch • TB and atypical mycobacteria (M. avium and M. scrofulaceum) • Management • Culture drainage or of pharyngeal exudate • Treatment • 1st/2nd generation cephalosporin or dicloxacillin • Clindamycin or Augmentin if anaerobe suspected (oral) • Ultrasound to determine if abscess • I&D indicated if abscess present

20. Infectious Mononucleosis • Symptoms • fever, pharyngitis, lymphadenopathy (symmetric involvement of posterior cervical nodes) • EBV, CMV, toxoplasmosis, Streptococcus, hep B, HIV • Testing • Monospot test (heterophile antibody) • High false negative in < 4 YO and early illness • Specific serologic tests • Elevated immunoglobulin M titer to viral capsid antigen (Igm-VCA) indicates acute infection

21. Diagnostic Testing to Consider • Blood • CBC, ESR, LDH • Specific Serologic testing (EBV, CMV, Bartonella) • Tuberculin Skin Testing • Chest X-ray • Biopsy