Download - lymphadenopathy]
600 lymph nodesSubmandibular, axillary, inguinal
regions Normally palpable in adults
Lymphadenopathy Nodes that are abnormal in either size,
consistency or numberGeneralized lymphadenopathy
defined as two or more sites with abnormal lymph nodes.
Lymph nodes Not generally palpable in the noenate Childhood:
▪ 1 cm cervical and axillary nodes▪ 5 mm epitrochlear lymphnodes▪ 1.5 cm inguinal nodes▪ Shotty adenopathy in the cervical, posterior auricular,
inguinal areas▪ Common▪ Often due to routine uncomplicated intercurrent
infections
In primary care patients with unexplained lymphadenopathy, ¾ of patients will
present with localized lymphadenopathy
¼ with generalized lymphadenopathy
Findings from a Dutch study revealed that only 10 percent of patients with unexplained adenopathy required referral to a subspecialist, and only 1 percent had a malignancy.
The cause of lymphadenopathy is often obvious: the child who presents with a sore throat,
tender cervical nodes and a positive rapid strep test,
the patient who presents with an infection of the hand and axillary lymphadenopathy.
In other cases, the diagnosis is less clear.
To present an approach to the diagnosis and management of patients who present with lymphadenopathy. Especially those whose diagnosis is “less
clear”.
HistoryAnd Physical Examination
Generalized LocalizedPossible SVC
syndrome
Duration Fever Weight loss Night sweats Inflammatory disease Neoplasia Sexual history Travel Recent
injuries/wounds/systemic infections/surgery/dental complications
pets
HistoryAnd Physical Examination
Generalized Localized Possible SVC syndrome
Age Size
2.5 cm cervical lymph nodes may be seen in intercurrent infections
Generalized: >2 non contiguous lymph node
groups Systemic disease
Localized Single set of nodes or contiguous
set of nodes Erythema Tenderness Warmth Fluctuance Dental disease Rashes Wounds Concomittant splenomegaly
HistoryAnd Physical Examination
Generalized Localized Possible SVC syndrome
Respiratory difficulties
Wheezing Facial swelling Plethora orthopnea
HistoryAnd Physical Examination
Generalized LocalizedPossible
SVC syndrome
HistoryAnd Physical Examination
Generalized LocalizedPossible SVC
syndrome
Generalized adenopathy
CBC, blood smear, ESR LDHUric acid, Renal and hepatic Function
Chest x-ray
None Simple viral illnesses
CBC abnormal white counts Anemia thromboctyopenia
PBS Atypical lymphocytes blasts
ESR Increases in infections +/- in malignancy
EBV titers Infectious
mononucleosis Mildly increased
transaminases Plus normal CBC
▪ Suggestive of viral illness
LDH Malignancies, hepatic
disease, hemolysis Uric acid, Phosphorus,
BUN, Calcium, K Chest xray
If with chest symptoms; Mediastinal adenopathy
Generalized adenopathy
Lab exams
Flu-like symptomsWeight loss, night sweats,
bone pain, Painless, progressivenode Enlargement
Abnormal labs
Suggestive of collagen vasular disease or chronic inflammation
disease
Infection likely High risk for malignancy No Yes
Generalized adenopathy
Lab exams
Flu-like symptomsWeight loss, night sweats,
bone pain, Painless, progressivenode Enlargement
Abnormal labs
Suggestive of collagen vasular disease or chronic inflammation
disease
Infection likely High risk for malignancy No Yes
Rhinitis Pharyngitis Malaise Headache Fever Ask:
TB exposure Sexual behavior Drug use Transfusion history
Weight loss (>10%) Malignancy Tuberculosis HIV
Nodes: Soft Tender Non-erythematous
Rash Hepatosplenomegaly
Mild to moderate Normal CBC or mild
leukopenia Atypical lymphos Normal uric acid ESR normal
Generalized adenopathy
Lab Exams
Flu-like symptomsWeight loss, night sweats,
bone pain, Painless, progressivenode Enlargement
Abnormal labs
Suggestive of collagen vascular disease
or chronic inflammation disease
Infection likely
Consider: EBV Varicella Rubella Mumps Toxoplasmosis Measles Chlamydia HIV TB Syphillis Fungal infection Collagen vascular and
inflammatory disorders
Appropriate serology may be done if indicated
Appropriate bacterial and fungal studies
Generalized adenopathy
Lab exams
Flu-like symptomsWeight loss, night sweats,
bone pain, Painless, progressivenode Enlargement
Abnormal labs
Suggestive of collagen vasular disease
or chronic inflammation disease
Infection likely
Yes NO
Suspicion of malignancy still persists?
Presumed viral illness Adenopathy continues to increase over a
2-week period or fails to resolve over a 6-week period
Other changes: Development of a more firm or matted
consistency of the nodes Supraclavicular adenopathy Weight loss Night sweats Respiratory distress
Generalized adenopathy
Lab exams
Flu-like symptomsWeight loss, night sweats,
bone pain, Painless, progressivenode Enlargement
Abnormal labs
Suggestive of collagen vasular disease or chronic inflammation
disease
Infection likely
Yes NO
Suspicion of malignancy still persists?
Generalized adenopathy
Lab exams
Flu-like symptomsWeight loss, night sweats,
bone pain, Painless, progressivenode Enlargement
Abnormal labs
Suggestive of collagen vasular disease or chronic inflammation
disease
Infection likely
Yes NO
Lymph node or BM biopsy
Suspicion of malignancy still persists?
Generalized adenopathy
Lab exams
Flu-like symptomsWeight loss, night sweats,
bone pain, Painless, progressivenode Enlargement
Abnormal labs
Suggestive of collagen vasular disease or chronic inflammation
disease
Infection likely
Yes NO
Lymph node or BM biopsy Treat/observe as appropriate
Suspicion of malignancy still persists?
Generalized adenopathy
Lab exams
Flu-like symptoms
Weight loss, night sweats, bone pain, Painless, progressive
node Enlargement Abnormal CBC, smear,
inc uric acid, inc LDH, abn CXR
Suggestive of collagen vasular disease or chronic inflammation
Infection likely High risk for malignancy No Yes
RashArthralgiaArthritisChronic symptomsMedication use Increased ESRAbnormal renal function
Generalized adenopathy
Lab exams
Flu-like symptoms
Weight loss, night sweats, bone pain, Painless, progressive
node Enlargement Abnormal CBC, smear,
inc uric acid, inc LDH, abn CXR
Suggestive of collagen vasular disease or chronic inflammation
No Yes
Anti-ds-DNA AntibodiesACE
Drug use
RASLE
SarcoidosisSerum sickness
Drug-induced lymphadenopathy
(+) ds-DNA RA SLE
Sarcoidosis Serum sickness
Phenytoin INH Hydralazine Dapsone Procainamide allopurinol
Generalized adenopathy
Lab exams
Flu-like symptoms
Weight loss, night sweats, bone pain, Painless, progressive
node Enlargement Abnormal CBC, smear,
inc uric acid, inc LDH, abn CXR
Suggestive of collagen vasular disease or chronic inflammation
No Yes
Anti-ds-DNA AntibodiesACE
Drug use
RASLE
SarcoidosisSerum sickness
Drug-induced lymphadenopathy
treat diagnosis
Generalized adenopathy
Lab exams
Flu-like symptoms
Weight loss, night sweats, bone pain, Painless, progressive
node Enlargement Abnormal CBC, smear,
inc uric acid, inc LDH, abn CXR
Suggestive of collagen vasular disease or chronic inflammation
Infection likely High risk for malignancy No Yes
R/O storage diseases
Generalized adenopathy
Lab exams
Flu-like symptoms
Weight loss, night sweats, bone pain, Painless, progressive
node Enlargement Abnormal CBC, smear,
inc uric acid, inc LDH, abn CXR
Suggestive of collagen vasular disease or chronic inflammation
Infection likely High risk for malignancy No Yes
R/O storage diseases
Check for massive splenomegalyDo leukocyte assays for storage
diseasesBM biopsy for some diseasesDifferentials:
Gaucher Nieman-Pick
Generalized adenopathy
Lab exams
Flu-like symptoms
Weight loss, night sweats, bone pain, Painless, progressive
node Enlargement Abnormal CBC, smear,
inc uric acid, inc LDH, abn CXR
Suggestive of collagen vasular disease or chronic inflammation
Infection likely High risk for malignancy No Yes
R/O storage diseases
Therapy: specific Storage disease
Generalized adenopathy
Lab exams
Flu-like symptoms
Weight loss, night sweats, bone pain, Painless, progressive
node Enlargement Abnormal CBC, smear,
inc uric acid, inc LDH, abn CXR
Suggestive of collagen vasular disease or chronic inflammation
Infection likelyHigh risk for malignancy
No Yes
Generalized adenopathy
Lab exams
Flu-like symptoms
Weight loss, night sweats, bone pain, Painless
, progressivenode Enlargement
Suggestive of collagen vasular disease or chronic inflammation
Infection likelyHigh risk for malignancy
No Yes
Weight loss Night sweats Bone pain Painless, progressive node
enlargement Suprclavicular adenopathy Nodes rubbery and fixed
to skin/underlying tissues malignancy
Shotty adenopathy In ALL
Waxing and waning Hodgkin disease Apparent response to
antibiotic therapy Tuberculous node
May be firm, matted and fixed to surrounding confusion
Abnormal CBC Increased uric acid Inc LDH Abnormal Chest xray
Do LN bxBMA aspirateBM biopsyNa, K, ca, Mg, Phosphorus, BUN, creaChest xray
Generalized adenopathy
Lab exams
Flu-like symptomsWeight loss, night sweats,
bone pain, Painless, progressive
node Enlargement
Suggestive of collagen vasular disease or chronic inflammation
High risk for malignancy
InfectionOther inflammatory
states
Hodgkin diseaseNHL
LeukemiaTumpr lysis syndrome
Generalized adenopathy
Lab exams
Flu-like symptomsWeight loss, night sweats,
bone pain, Painless, progressive
node Enlargement
Suggestive of collagen vasular disease or chronic inflammation
High risk for malignancy
InfectionOther inflammatory
states
Hodgkin diseaseNHL
LeukemiaTumpr lysis syndrome
Differential dx for malignancy Hodgkin disease NHL Leukemia Neuroblastoma Rhabdomyosarcoma Histiocytici disroders Treatment: chemotherapy
HistoryAnd Physical Examination
Generalized LocalizedPossible SVC
syndrome
Localized adenopathy
occipital
periauricular
cervical
submaxillary
supraclavicular
axillary
Mediastinal
abdominal
ilioinguinal
Localized adenopathy
occipital
periauricular
cervical
submaxillary
supraclavicular
axillary
Mediastinal
abdominal
ilioinguinal
Occipital Consider scalp
infections▪ Pediculosis capitus▪ Tinea capitis▪ Secondary infection of
seborrheic dermatitis
Rubella Roseola malignancy
Periauricular Cat scratch disease Eye infections Skin infections tularemia
Localized adenopathy
occipital
periauricular
cervical
submaxillary
supraclavicular
axillary
Mediastinal
abdominal
ilioinguinal
Cervical Streptococcal tonsilitis Viral infection URTI Acute adenitis EBV Malignancy
▪ ALL, NHL, neuroblastoma
▪ Hodgkin▪ Thyroid CA, NPCA,
fibrosarcoma
Kawasaki disease Toxoplasmosis Nonlymphoid masses
▪ Cystic hygroma▪ Giuter▪ Thyroid CA▪ Branchial cleft cysts▪ Sternocleidomastoid
tumors▪ Teratomas▪ Dermoid cysts▪ hemangiomas
Sinus histiocytosis TB
Localized adenopathy
occipital
periauricular
cervical
submaxillary
supraclavicular
axillary
Mediastinal
abdominal
ilioinguinal
Submaxillary Local infections of
the teeth and mouth
Acute lymphadenitis
Hodgkin disease NHL TB malignancy
Supraclavicular Very concerning Warrant biopsy Malignancy TB Histoplasmosis coccidioidomycosis
Localized adenopathy
occipital
periauricular
cervical
submaxillary
supraclavicular
axillary
Mediastinal
abdominal
ilioinguinal
Axillary Infections of the arm and
axilla Cat scratch disease Reactions to
immunizations malignancies
Mediastinal ALL NHL Hodgkin Neuroblastoma TB Fungal infection Teratoma Thyroid CA Thymoma Sarcoidosis
▪ Bilateral hilar LAD▪ Pulmonary parenchymal
infilteration, hypercalcemia▪ Incb ACE levels
Cystic fibrosis
Localized adenopathy
occipital
periauricular
cervical
submaxillary
supraclavicular
axillary
Mediastinal
abdominal
ilioinguinal
Abdominal NHL Hodgkin Mesenteric adenitis Other malignancies
Ilioinguinal Infections of
leg/groin Syphillis Lymphogranuloma
venereum plague
Localized adenopathy
Assess all clinical data
Likely acute adenitis Or related to bacterial
infectionSuspected viral illness
Suspicious of malignancy
Non-lymphoid mass
>1 cm in the cervical region Usually viral or bacterial Nodes decrease in 2-6 weeks
Persisting >6 weeks or continuing to increase for more than 2 weeks Do biopsy
Firm, nontender nodes Malignant
Tender, warm, erythematous, fluctuant, very mild anemia Infection
CBC Neutropenia, anemia, thromobocytopenia
LDH, phosphorus, uric acid
Localized adenopathy
Assess all clinical data
Likely acute adenitis Or related to bacterial
infectionSuspected viral illness
Suspicious of malignancy
Non-lymphoid mass
Localized adenopathy
Assess all clinical data
Likely acute adenitis Or related to bacterial
infectionSuspected viral illness
Suspicious of malignancy
Non-lymphoid mass
Treatment: Trial of antibiotics Surgical drainage
Localized adenopathy
Assess all clinical data
Likely acute adenitis Or related to bacterial
infectionSuspected viral illness
Suspicious of malignancy
Non-lymphoid mass
Localized adenopathy
Assess all clinical data
Likely acute adenitis Or related to bacterial
infectionSuspected viral illness
Suspicious of malignancy
Non-lymphoid mass
Observe for 2-6 weeks
Lab studies if questionnable diagnosis, progressively enlarging adenopathy, new symptoms or signs or failure to resolve after 6 weeks
Localized adenopathy
Assess all clinical data
Likely acute adenitis Or related to bacterial
infectionSuspected viral illness
Suspicious of malignancy
Non-lymphoid mass
Localized adenopathy
Assess all clinical data
Likely acute adenitis Or related to bacterial
infectionSuspected viral illness
Suspicious of malignancy
Non-lymphoid mass
Do radiologic studies Ultrasound Xrays CT MRI Biopsy or excision
Localized adenopathy
Assess all clinical data
Likely acute adenitis Or related to bacterial
infectionSuspected viral illness
Suspicious of malignancy
Non-lymphoid mass
Failure to improve, symptoms or laboratory findings suggestive of malignancy
Localized adenopathy
Assess all clinical data
Likely acute adenitis Or related to bacterial
infectionSuspected viral illness
Suspicious of malignancy
Non-lymphoid mass
Failure to improve, symptoms or laboratory findings suggestive of malignancy
Suspicious of malignancy Work-up discussed
previously▪ CBC▪ Blood smear▪ renal/hepatic fxn▪ LDH, uric acid, Ca, P▪ CXR▪ Possible CT
Early LN biopsy▪ Largest, most recently
enlarging lymph node▪ NOT always the
easiest/most accessible node