Download SPLENOMEGALY and LYMPHADENOPATHIES

SPLENOMEGALY
and
LYMPHADENOPATHIES
Hasan Atilla Özkan, MD.
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LYMPHADENOPATIES
1- Anatomy and Definitions
• Lymph node regions in the body
- head and neck
- supraclavicular
- deltopectoral
- axillary
- epitroclear
- inguinal
- popliteal
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• Normal lymph nodes are usually less than 1 cm
in diameter (tend to be larger in adolescence
than later in life)
• Lymph nodes are often palpable in the inguinal
region in healthy people, may also be papable in
the neck (particularly submandibular) ; because
chronic trauma and infection is more common in these
regions
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2. Diagnostic approach
A – History
B – Physical examination
C – Diagnostic tests
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1. History
• Localizing signs or symptoms suggesting
infection or malignancy
• Exposures likely to be associated with infection
(cat stratch disease, high risk behavior)
• Constitutional symptoms such as fever, night
sweets or weight loss
• Use of medications that can cause
lymphadenopathy
• Foreign travel
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2. Physical examination
All lymph node groups should be examined
with the following characteristics in mind:
• Location
• Localized or generalized
• Size
• Tenderness
• Consistency
• Fixation
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Location - 1
• Localized lymphadenopathy
- suggest local causes, search for pathology
in the area of node drainage
- some systemic disease can also present
with localized adenopathy
* tularemia
* aggressive lymphoma, etc
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Location - 2
• Cervical adenopathy
- bacterial infections
- infectious mononucleosis
- toxoplasmosis
- tuberculosis
- lymphoma
- kikuchi’s disease
- head and neck malignancies
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Location – 3
• Supraclavicular lymphadenopathy
- is associated with high risk of
malignancy
- right supra: mediastinum, lungs or
esophagus
- left supra (Virchow’s node):
abdominal malignancy
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Location - 4
• Axillary
- drainage from the arm, thoracic wall
and breast
- infections are common causes
-in the absence of upper extremity
lesions, cancer is often found
(particularly breast cancer)
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Location - 5
• Epitrochlear
- always pathologic
- infections of the forearm and hand,
lymphoma, sarcoidosis, tularemia and
secondary syphilis
• Inguinal
- usually caused by lower extremity infection,
sexually transmitted disease or cancer
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Location - 6
• Generalized lymphadenopathy
- Usually a manifestation of systemic disease
* HIV infection
* mycobacterial infection
* infectious mononucleosis
* systemic lupus erythematosis
* medications
* lymphoma / leukemia
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3. Diagnostic tests
• Laboratory testing
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CBC
Chest X-ray
PPD
HIV Ab
ANA
Other spesific test in need
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• Lymph node biopsy;
(If an abnormal node has not resolved after 4
weeks or suspect of malignancy)
- Open biopsy: genarally is the best test
- Fine needle aspiration: useful when searching
for reccurence of cancer
- Core needle biopsy: in situtition where the
open lymph node biopsy can not be performed
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• Incision and drainage
• Imaging
• Observation over time
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SPLENOMEGALY
A. General Information
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Hematopoietic organ capable of supporting elements
of the erythroid, myeloid, megakaryositic, lymphoid
and monocyte-macrophage systems
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Participates in cellular and humoral immunity through
its lymphoid elements
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Removes senescent RBC, bacteria, and other
particules from the circulation through monocytemacrophage system (major function)
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• Splenectomized patients are suspectible to bacterial
sepsis, especially with uncapsulated ones
• Major lymphoid organ, containing ~ 25% of the total
lymphoid mass of the body
• About 1/3 of circulating plateletes are suspected in the
spleen where they are in equilibrium with circulating
plateletes
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B. Size and Palpability
• Median weight is about 150 grams
• Average estimated weight of palpable spleen is about
285 grams
• Not usually palpable, but may be felt in children,
adolescents and some adults, especially those of
asthenic build
• A palpable spleen usually means the presence of
significant splenomegaly
• Enlarged spleen on physical examination is more reliable
than minimally enlarged on imaging
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• The clincal or diagnostic significance of a spleen that is
minimally enlarged on scan but is not palpable
(scanomegaly) is uncertain
• Symptoms of an enlarged spleen may include;
- pain, a sense of fulness, or discomfprt in the left upper
quadrant
- pain referred to the left shoulder
- early satiety, due to encrachment on the adjacent
stomach
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• Criterias proposed to define the size of normal spleen;
* USG – length < 13 cm or thichness ≤ 5 cm
* CT scanning – length ≤ 10 cm
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C. Causes of Splenomegaly
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The causes of enlarged spleen are multiple:
- most reflect the presence of hepatic or
hematologic disease, infection or inflammation
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• Common causes
- liver disease : 33% (cirrhosis)
- hematologic malignancy : 27% (lymphoma)
- Infection : 23% (AIDS, endocarditis)
- congestion or inflammation : 8%
- primary splenic disease: 4% (splenic vein
thrombosis)
- other or uncommon : 5%
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• Massive splenomegaly
- chronic myeloid leukemia
- myelofibrosis
- gaucher disease
- lymphoma
- Kala-azar (visceral leishmaniasis)
- malaria
- beta-thalassemia major
- AIDS with mycobacterium avium complex
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D. Evaluation
• History:
- chronic alcholism, hepatitis
- fatigue, fever, sore throat: inf. Mononucleosis
- post-bath pruritis: polycytemia vera
• Imaging studies
• CBC and pheripheral blood smear
• Bone marrow asp. and biopsy
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• Diagnostic splenctomy
* most common pathologic diagnosis;
- leukemia / lymphoma 57%
- metastatic carcinoma 11%
- cyst / pseudocyst 9%
- beningn / malign vascular neoplasm 7%
- normal 5%
• Splenic aspiration / biopsy
- is not widely practiced because of a
concern for bleeding
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• General indications for splenectomy
- isolated thrombocytopenia, hemolytic
anemia or neutropenia
- painfully enlarged spleen
- traumatic or atraumatic splenic rupture
- splenic artery aneurysm
- hypersplenism
- splenic vascular or parencymal lesion
- to allow diagnosis
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• Spesific conditions in which splenectomy may be
considered;
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İmmune thrombocytopenia
Autoimmune hemolytic anemia
Thalassemia major or intermedia
Hereditory spherocytosis
Primary myelofibrosis
Hairy cell leukemia, splenic marginal zone lymphoma
Splenic contusion or rupture
Splenic abscess or infection
Splenic vein thrombosis with bleeding varices
Felty’s syndrome
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