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Lymphadenopathy
Case
41 yo male school teacher presents to your office with right sided
cervical lymphadenopathy. His past medical history is significant
for hypertension and dyslipidemia. His medications include hctz
and simvastatin. NKDA. 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.
B. Proceed to fine needle aspiration.
C. Check a CXR and cbc.
D. Have patient follow up in 3-4 weeks.
Learning Objectives
Provide an approach to the patient with
peripheral lymphadenopathy
Be able to differentiate between benign and
serious illness
Knowledgeable of nodal distribution and
anatomic drainage
Present a substantial differential diagnosis
Indications for nodal biopsy
Definition: Lymphadenopathy
Lymph nodes that are abnormal in
size, consistency or number
Generalized
Localized
Lymphatic System
Network that filters antigens from the interstitial fluid
Primary site of immune response from tissue
antigens
Lymphatic drainage in all organs of the body except
brain, eyes, marrow and cartilage
Flaccid thin walled channelsprogressive caliber
600 lymph nodes in body
Slow flow, low pressure system returns interstitial
fluid to the blood system
Secondary lymphoid tissue
Lymph nodes
Capsular shell
Fibroblasts and reticulin
fibers
Macrophages
Dendritic cells
T cells
B cells
Peripheral lymphadenopathy
Most cases benign, self limited illness
Primary or secondary manifestation of 100
illnesses
The CHALLENGE is to decide if it is
representative of a serious illness
Parameters to help
distinguish between
benign and serious
illness
Age
Character
Location
Malignancy much more
common in patients
greater 50 yrs of age
Not exactly
Epidemiology
Lee et al 1980 Referral centers 925
underwent a lymph node biopsy.
Age <30 79% benign 15% lymphomatous
6% carcinomas
Age >50 40% benign 16% lymphomatous
44% carcinomas
Age 30-50 indeterminate values
Dutch study Fijten 1988
0.6 annual incidence of generalized
lymphadenopathy
2,556 present with unexplained
lymphadenopathy
10% referred to subspecialist3.2% required
bx and of that 1.1% had a malignancy
40 yrs + 4% risk of cancer vs. 0.4% risk in pts
younger than 40
Lymph node character
Size
Site
Consistency
Pain with palpation
Size
Greater than one centimeter generally
considered abnormal
Exception inguinal area, lymph nodes
commonly palpated (>1.5 cm)
Size does not indicate a specific disease
process
Obese and thin population
Pain..
Indication of rapid increase in size: stretch of
capsular shell
NOT useful in determining benign vs
malignant state
Inflammation, suppuration, hemorrhage
Consistency
Stone hard: typical of cancer usually
metastatic
Firm rubbery: can suggest lymphoma
Soft: infection or inflammation
Shotty buckshot under skin
Suppurated nodes: fluctuant
Detect node from stroma
Matting
Location, location, location
Post cervical: scalp, neck skin of arms thorax cervical and axillary nodes (lymphoma, head/neck ca)
Supraclavicular Nodes
Drain the mediastinum and abdomen
Hodgkin, NHL
Melanoma (drains back of arm)
Staph/strep
Cat scratch
Silicone prosthesis
Inguinal lymphadenopathy
Drain the lower extremity, genitalia, buttocks,
abdominal wall
Normal
People who walk barefoot
Squamous cell carcinoma of penis or vulva
Venereal disease
Epitrochlear
Lymphoma/CLL
Mono
Historically associated with syphilis, rubella,
leprosy
Studies to indicate an association with early
HIV disease in sub-Saharan Africa, areas
with high prevalence of disease
Hilar, mediastinal, abdominal
>1 cm considered pathological
Pneumonia/inflammatory process can cause
unilateral hilar disease
Lymphadenopathy limited to abdomen likely
malignant
Highest rate of malignancy
Right Supraclavicular Left Supraclavicular
Mediastinum Virchow node
Lungs Testes/ovaries
Upper 2/3 esophagus Kidneys
Pancreas
Prostate
Stomach
Lower Esophagus
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
Presentation of
lymphadenopathy
Unexplained
lymphadenopathy
3/4 presents with
localized
1/4 present with
generalized
Algorithm to evaluate
Lymphadenopathy
CHICAGO
Chicago
Cancer
Heme malignancies: Hodgkins, NHL, acute
and chronic leukemias, waldenstroms,
multiple myeloma (plastmocytomas)
Metastatic: solid tumor breast, lung, renal,
cell ovarian
cH icago
Hypersensitivity syndromes
Drugs sickness
Serum
Serum sickness like illness
Silicone
Vaccination
Graft vs Host
Specific Medications
Dilantin
Cephalosporins
Atenolol
Sulfonamides
Captopril
Carbamazepine
Primodine
Gold
Allupurinol
i
Ch cago
Infections
Viral
Bacterial
Protozoan
Mycotic
Rickettsial (typhus)
Helminthic (filariasis)
VIRAL
EBVmono spot test
CMV.cmv titers, immunsuppresed,
transplant recipient, recent blood transfusion
HIVIV drug use, high risk sexual behavior
Hepatitis.IV drug use
Herpes Zoster.superficial cutaneous
nodules
Bacterial
Staph/strep: cutaneous source, lymphadenitis
Cat scratch: bartonella hensalae, two weeks
after inoculation
Mycobacterium: TB and non-tb, host
characteristics (HIV, foreign born, low
socioeconomic status, homeless)
Spirochete
Syphilis: Treponema pallidum Primary
localized inguinal lymph nodes and
secondary, non-treponemal, treponemal
Lyme disease
Protozoan
Toxoplasmosis: ELISA assay, intracellular
protozoan toxoplasmosis gondii.bilateral,
symmetrical, non-tender cervical adenopathy
consider undercooked meat, reactivation in
immuncompromised host
chi cago
Connective Tissue Disease
Rheumatoid Arthritis
SLE
Dermatomyositis
Mixed connective tissue disease
Sjogren
a
chic go
Atypical lymphoproliferative
disorders
Castlemans disease
Wegeners
Angioimmuonplastic lymphadenopathy with
dysproteinemia
chica Go
Granulomatous
Histoplasmosis
Mycobacterial infections
Cryptococcus
Silicosis: coal, foundry, ceramics, glass
Berylliosis: metal, alloys
Cat Scratch
My cat Pigeon
OTHER.chicago
RARE
Kikuchi
Rosia Dorfman
Kawasaki
Transformation of germinal centers
Limited
Unexplained