Clinical approach to Lymphadenopathy

EVALUATION OF LYMPHADENOPATHY

Nearly 600 lymphnodes

Normally palpable

Sub mandibularAxillary

inguinal

Pathophysiology

React to threat

Hyperplastic response that usually resolves within 1 month

Clinical presentations

1.Size & quality

Palpable nodes in other regionsAny node >1cm

abnormal

Nodes >3cm neoplasm

2.Accompanying symptoms

2.Accompanying symptoms

r/c fever >38.5 C,night sweats,weigt loss

LYMPHOMAS

Lymphngectic streaking

splenomegaly

3.Distribution

GENERALISED

•IMN•AIDS•AIDS related complex•Toxoplasmosis•Secodary syphilis

infections

•Serum sickness•Phenytoin•Vasculitis,lupus,RA

Hypersensitivity

•LEUKEMIA•HODGKIN’S DISEASE•NHL

Neoplasia

METABOLIC •Hyper thyroidism•Lipidoses

Castleman’s disease

Rare,idiopathic,Localised/multicentric,mimic lymphoma/HIV,systemic symptoms,increased risk of infection

LOCALISED•Viral Conjunctivitis•Trachoma•Tularemia•Sarcoidosis

ANT.AURICULAR

•Rubella•Scalp infection

POST.AURICLA

R

ANT. AURICULAR POST. AURICULAR

• Buccal cavity infection• Pharyngitis• Nasopharyngeal tumour• Thyroid malignancy

SUB MANDIBULAR

•IMN•Sarcoidosis•Toxoplasmosis•pharyngitis

CERVICAL B/L

SUB MANDIBULAR CERVICAL B/L

• Pulmonary malignancy• Mediastinal malignancy• Esophageal malignancy

Right Supra

clavicular

• Intra abdominal malignancy

• Renal ca• Testicular or ovarian

malignancy

Left supra

clavicular

RIGHT SUPRA CLAVICULAR LEFT SUPRA CLAVICULAR

•Ca breast / infection•Upper extremity infection

axillary

•Syphilis(b/l)..Sailor’s handshake•CLL•IMN•Lymphoma•Hand infection(u/l)

Epitrochlear

AXILLARY LYMPHADENOPATHY

EPITROCHLEAR LYMPHADENOPATHY

•Syphilis•Genital herpes•Lympho granuloma venereum•Chancroid•Lower extremity/local infection

Inguina

l

INGUINAL LYMPHADENOPATHY

•Lymphoma•Bronchogenic ca•TB•sarcoidosis

Hilar(u/l)

•Sarcoidosis•Fungal(histoplasmosis,coccidiomycosis)•Lymphoma•Bronchogenic ca•TB

Hilar(b/l)

UNILATERAL HILAR LYMPHADENOPATHYBILATERAL HILAR LYMPHADENOPATHY

•Adeno ca of gut•Hodgkin’s d/s•TB•Bladder ca•Gastric ca

ABDOMINA

L

GASTRIC CA

SISTER MARY JOSEPH NODULE

•Cat scratch fever•Hodgkin’s d/s•NHL•Leukemia•Metastatic ca•Sarcoidosis•Granulomatous infection

ANY REGION

CAT SCRATCH D/S

4.other lymphatic abnormalitiesLymphangitisLymphadenitisKikuchi’s diseaselymphedema

History & examination

1.Is the palpable mass indeed a lymph node????

Enlarged parotidThyroglossal cystAbscessBranchial cyst

2.Acute or chronic ??

3.Character of enlarged node???tender.,mobile

Firm,rubbery,nontenderPainless,stonehard,fixed&matted

4.Localized or generalised??

5.Are there associated systemic/localizing symptoms/signs???

6.Are there unusual epidemiological clues???

Exposure to catsTravelExposure to bird droppingsLacerations during gardeningExposure to TBSexual exposure

Laboratory investigations

1.Complete blood cell count with differential….

Atypical lymphocytosisEosinophiliaPancytopenia

2.Serum uric acid

3.Serum liver chemistries

Localised adenopathy

1.Throat culture

2.Urethral/cervical swabs

3.Blood culture

4.biopsy

5.Abdominal CT

6.Bone marrow biopsy

Heterophile testVDRLAntibody titres of viruses,fungi,toxoplasmosisAnti nuclear antibodiesRheumatoid factor

1.Serological tests

Generalised adenopathy

Hilar adenopathy

1.Mantoux test

3.ACE enzyme determination

4.Bronchoscopy

5.mediastinoscopy

2.chest X-RAY,CT

Lymph node biopsyMost direct approach

Indications

Approaches & yeild Excitional biopsy

prefferedFNACNeedle aspiration

Choice of nodeLargest nodeAvoid inguinal & axillarySupra clavicular-highest diagnostic yield

complicationsFollow up/empiric treatment

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