Download Lymphadenopathy

This lecture was conducted during the Nephrology
Unit Grand Ground by Medical Student rotated under
Nephrology Division under the supervision and
administration of Prof. Jamal Al Wakeel, Head of
Nephrology Unit, Department of Medicine and Dr.
Abdulkareem Al Suwaida. Nephrology Division is not
responsible for the content of the presentation for it is
intended for learning and /or education purpose only.
Lymphadenopathy
A Systematic Approach
Abdulaziz F. Al Mana
Medical Student
Case

35 yo male taxi driver presents to your office with right
sided cervical lymphadenopathy. His past medical history is
unremarkable. His not taking any medications. He noticed
the lump in his neck last week. He has not experienced any
fevers, chills or weight loss. He denies any sore throat, ear
pain or dental problems. His vital signs are stable. On
physical exam he has a 2cm anterior cervical lymph node
which is firm, non-tender and mobile. His HEENT exam is
unremarkable. No skin lesions are evident. No other
lymphadenopathy is found. How should you proceed with
this patient?
A.
Location and duration typical for viral etiology. Have your
patient follow up for annual physical next year.
Proceed to fine needle aspiration.
Check a CXR and cbc.
Have patient follow up in 3-4 weeks.
B.
C.
D.
Definition: Lymphadenopathy
One or more lymph nodes that are
abnormal in size, consistency, or number.
 Benign/self limiting or serious underlyng
disease.
 Generalized
 Localized

Evaluation: History & Examination
 Key Points:
 AGE
 LOCATION
 NUMBER (local or generalized “ 2 or more”)
 +/- SYSTEMIC SIGNS/SYMPTOMS
 +/- SPLENOMEGALY
 SIZE, CONSISTENCY, TENDERNESS,
FIXATION and OVERLYING SKIN
 DRUG Hx
 Hx of EXPOSURES
AGE
Very IMP
 Helps predict the likelihood of a benign vs.
malignant process
 Patients < 30 yrs (benign 80% of the time)
 Patients > 50 yrs (malignant 60 % of the
time)

LOCATION
3 major regions: H&N(including oral
cavity), Axilla and Inguinal regions.
 Other: Epitrochlear, Popliteal, Para-aortic
and supraclavicular regions.

ASSOCIATED SIGNS/SYMPTOMS







Constitutional: Fever, chills, night sweats and weight
loss (>10%body wt >6month) “ B symptoms”
Anemic symptoms (weakness, tiredness,
breathlessness,..)
Bone pain
Bleeding tendency(epistaxis, bruising,..)
Local disease (ear, throat, skin, teeth,..)
+/- Splenomegaly and/or hepatomegaly (IMP)
Rash, arthralgia, arthritis, mucous membrane lesions
CHARACTER

Size: Large > 1 cm (abnormal)
Exceptions: * inguinal region (> 1.5 cm)
* Obese and thin individuals

Consistancy:
Stone hard: typical of cancer usually metastatic.
Firm rubbery: can suggest lymphoma
Soft: infection or inflammation
 Fixation: fixed, non mobile nodes are more likely to be
infiltrated by carcinoma than mobile nodes.
 Matting: A group of nodes that feels connected and seems
to move as a unit.
Nodes that are matted can be either benign (e.g., tuberculosis,
sarcoidosis or lymphogranuloma venereum) or malignant (e.g.,
metastatic carcinoma or lymphomas).
cont. CHARACTER

Tenderness:
Indication of rapid increase in size: stretch of
capsular shell
NOT useful in determining benign vs malignant
state
Inflammation, suppuration, hemorrhage

Overlying skin:
Inflamed skin: warm, erythematous suggests infection
Tethered skin: suggests carcinoma
Other: sinus , ulceration,..
History of Exposures

Cats: cat scratch disease, Toxoplasmosis

Unpasteurized milk: Brucellosis
Uncooked meat: Toxoplasmosis
 Ticks: Lyme disease
 Blood transfusion/ transplants: CMV,

HIV
High risk sexual behavior: STD
 IVDU: HIV, Endocarditis, HBV
 Travel Hx: Many possibilities

Drug History
•
•
•
•
Specific medications: eg:
Antibiotics: Sulphonamides, Penicillins,
Cephalosporins
Anticonvulsants: Phenytoin, Carbamazepine
Antihypertensive: Captopril, Hydralazine,
methyldopa
• Allopurinol
• Gold
• Sulphas
Evaluation: Differential diagnosis

A) By LOCATION:
Famous nodes
Virchows
Left supraclavicular (abdominal or
thoracic ca)
 Sister Joseph
Para-umbilical (gastric adenoca)
 Delphian node
Prelaryngeal (thyroid or laryngeal ca)
 Node of Cloquet (Rosenmuller node)
Deep inguinal near femoral canal


B) By Cause: “CHICAGO”
Cancer
Hypersensitivity
Infectons
Connective tissue disease
Atypical lymphoproleferative
disorders
Granulomatous
Other
CANCER

Hematologic: lymphoma (Hodgkins, NHL),
leukemia, waldenstroms, multiple myeloma
(plastmocytomas).

Solid tumors(metastatic):
H&N cancers  Cervical
Thoracic and abdominal ca  Supraclavicular
Breast ca, melanoma  Axillary
Squamous cell ca, melanoma  Inguinal
Hypersensitivity syndromes
Also known as serum sickness syndromes
 Causes:
 Drug reaction
 Vaccinations
 Exposure to animal serum
 Graft vs host

Infection
Viral: EBV, CMV, HIV, HSV, Herpes zoster,
HBV
 Bacterial: Staph/strep(cellulitis, Pharyngitis,
abcess, lymphadenitis), salmonellosis, cat
scratch( B.henslae 2 w after inoculation),
mycobacterial (TB or non TB), Spirochete
(Syphilis, Lyme disease)
 Fungal: Histo, Cryptococossis
 Parasitic: Toxoplasmosis,leshmaniasis Filariasis

Connective Tissue Disease
Rheumatoid Arthritis
 SLE
 Dermatomyositis
 Mixed connective tissue disease
 Sjogren

Atypical lymphoproliferative
disorders
Castleman’s disease
 Angioimmunoblastic lymphadenopathy
with dysproteinemia

Granulomatous
Histoplasmosis
 Mycobacterial infections
 Cryptococcus
 Sarcoidosis
 Silicosis: coal, foundry, ceramics, glass
 Berylliosis: metal, alloys
 Cat Scratch

Other
RARE
 Kikuchi
 Rosia Dorfman
 Kawasaki
 Transformation of germinal cente

Evaluation: Investigations











Directed toward the most likely cause.
Includes:
CBC
ESR
Renal and liver function
LDH
Serology and confirmatory tests
CXR
CT
FNA
Biopsy ( BEST but not always )
When to biopsy?
Lymphadenopathy from an infectous etiology
can be diagnosed without biopsy.
 Biopsy is indicated when malignancy is
suspected.
 FNA for cytology is usually sufficient to evaluate
for metastatic malignancies ( NOT the case if
lymphoma is suspected Excisional biopsy)

cont. When to biopsy?
In case of localized lymphadenopathy (Benign clinical
history, unremarkable physical examination and no
constitutional symptoms): reexamine in three to four
weeks to see if the lymph nodes have regressed or
disappeared.
 In case of unexplained localized lymphadenopathy &
constitutional symptoms or signs, if persists for three
to four weeks or high risk for malignancy or serious
illness should undergo a biopsy.
Note: Patients with probable viral illness biopsy should
be avoided because lymph node pathology in these
patients may sometimes simulate lymphoma and lead
to a false-positive diagnosis of malignancy.

Unexplained Generalized
lymphadenopathy
Always requires an evaluation
 Start with CXR and CBC
 Review Medications
 PPD, RPR, Hepatitis screen, ANA, HIV
 No yield on above tests: Biopsy most
abnormal node

Conclusion



Key factors to consider when evaluating a
patient with lymphadenopathy includes: Age,
location, and associated symptoms.
Most cases are due to infections, malignancy,
and immunologic disorders.
Lymphadenopathy is most likely due to a
benign self-limited infectious process in
younger individuals or may be a sign of a
serious underlying disease such a malignancy
in older individuals.
Case

35 yo male taxi driver presents to your office with right
sided cervical lymphadenopathy. His past medical history is
unremarkable. His not taking any medications. He noticed
the lump in his neck last week. He has not experienced any
fevers, chills or weight loss. He denies any sore throat, ear
pain or dental problems. His vital signs are stable. On
physical exam he has a 2cm anterior cervical lymph node
which is firm, non-tender and mobile. His HEENT exam is
unremarkable. No skin lesions are evident. No other
lymphadenopathy is found. How should you proceed with
this patient?
A.
Location and duration typical for viral etiology. Have your
patient follow up for annual physical next year.
Proceed to fine needle aspiration.
Check a CXR and cbc.
Have patient follow up in 3-4 weeks.
B.
C.
D.