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LYMPHADENOPATHY & SPLENOMEGALY Martin H. Ellis MD Meir Hospital CLINICAL ANATOMY OF THE LYMPH NODES Head & Neck – occipital, postauricular, preauricular, anterior cervical chain, posterior cervical chain, submandibular, submental, Waldeyer’s ring Clavicular – supra and infra Axillary – lateral, medial, posterior, apical Epitrochlear Inguinal Femoral Femoral Femoral Femoral RADIOLOGICAL ANATOMY OF LYMPH NODES Mediastinal Perihilar Retroperitoneal Mesenteric Iliac Hilar adenopathy (sarcoidosis) Mediastinal adenopathy (lymphoma, sarcoma, teratoma) DIAGNOSIS History & Physical diagnosis Laboratory testing CT scanning MRI Isotope scanning PET-CT scanning Histologic diagnosis APPROACH TO DIAGNOSIS Localized vs. generalized (including splenomegaly) History Physical exam Special investigations CHARACTERISTICS OF ENLARGED NODES Size – < 1cm=normal Pain/Tenderness – inflammation/rapid growth Consistency – stony, rubbery, firm, soft, fluctuant Matting – a group of nodes that seem joined Mobility Location DIFFERENTIAL DIAGNOSIS Congenital Acquired – – – – – – – – Infectious – bacterial,viral,fungal,parasitic,mycobacterial Inflammatory – autoimmune, allergic, vasculitic Neoplastic – benign, malignant (primary,secondary) Toxic & Metabolic – storage diseases, hyperthyroidism Drug – hydantoin, gold Traumatic Idiopathic – sarcoidosis, Castleman disease Iatrogenic – silicone implants SITE-DISEASE ASSOCIATIONS Occipital – rubella Supraclavicular – TB (scrofula), lung ca, gastric ca (Virchow node- Trousseau sign) Axillary – breast ca Inguinal – STDs Umbilical – ovarian ca (Sister Joseph’s node) Hx / PE DIAGNOSTIC eg local infection,tumor SUGGESTIVE eg mono,HIV,lymphoma UNEXPLAINED SPECIFIC TESTING POSITIVE TREAT CONDITION GENERALIZED LOCALIZED Review epidemiology Review medications POSITIVE DIAGNOSTIC POSITIVE MONONUCLEOSIS SEROLOGY PPD,HIV,HBV,CXR No serious illness apparent Observe 3-4 weeks Biopsy NEGATIVE Resolved BIOPSY ABNORMAL NODE Serious illness apparent Biopsy SPLENOMEGALY: DIAGNOSIS History & Physical diagnosis Laboratory testing CT scanning MRI Isotope scanning PET-CT scanning Histologic diagnosis DIFFERENTIAL DIAGNOSIS Congenital Acquired – Infectious – bacterial,viral,fungal,parasitic,mycobacterial – Inflammatory – autoimmune (SLE, Felty syndrome) – Neoplastic – benign, malignant (primary,secondary) – Toxic & Metabolic - (storage diseases eg Gaucher) – Congestive splenomegaly – portal hypertension – “Work” hyperplasia- chronic hemolytic anemias MASSIVE SPLENOMEGALY Tumors – Lymphoma, myeloproliferative disorders, Hairy cell leukemia Infections – Kala-azar (trypanosomiasis) Portal hypertension Gaucher disease Approach to diagnosissplenomegaly Known illnesses – eg lymphoma, SLE Current clinical context – Fever, recent travel, murmers Imaging studies – Size, focal lesions Histologic diagnosis – Splenectomy, ?splenic biopsy