lymphadenopathy uniba 18-1-13

7/29/2019 Lymphadenopathy Uniba 18-1-13

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Approach to

LymphadenopathyDr Putra Hendra SpPD

UNIBA


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Definition

Approx 600 LN in body

LAN = abnl size,

number, consistency

Generalized vs Local

Peripheral (central LAN

presents differently)


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Lymph Nodes

Anatomy

Collection of lymphoid cells attached to both vascular and

lymphatic systems

Over 600 lymph nodes in the body Function

To provide optimal sites for the concentration of free or cell-

associated antigens and recirculating lymphocytes

sensitization of the immune response To allow contact between B-cells, T-cells and macrophages

Lymphadenopathy - node greater than 1cm in size


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Why do lymph nodes enlarge?

Increase in the number of benign lymphocytesand macrophages in response to antigens

Infiltration of inflammatory cells in infection

(lymphadenitis) In situ proliferation of malignant lymphocytes or

macrophages

Infiltration by metastatic malignant cells Infiltration of lymph nodes by metabolite laden

macrophages (lipid storage diseases)


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Definitions

Pathologic Lymph Node

>2cm in children is considered abnormal

Acute Lymphadenopathy < 2 weeks duration

Subacute Lymphadenopathy

2-6 weeks duration Chronic Lymphadenopathy

> 6 weeks duration


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Epidemiology

0.6% annual incidence of unexplained

adenopathy in the general population

10% were referred to a subspecialist and 3.2 %

required a biopsy and 1.1% had a malignancy


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Epidemiology

Larsson et al. 38-45% of normal children have palpablecervical lymphadenopathy

Park et al. 90% of children aged 4-8 have lymphadenopathy

These masses can be mistaken for other local and systemicprocesses

Congenital Masses

Malignancies

Local presentation of systemic disease

Found by parents and caregivers and demand workup


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Physical Exam General

Febrile or toxic appearing

Skin

Cellulitis, impetigo, rash

HEENT

Otitis, pharyngitis, teeth, and nasal cavity

Neck Size

Unilateral vs Bilateral

Tender vs Nontender

Mobile vs Fixed

Hard vs Soft Lungs

Consolidations suggesting TB

Abdomen

Hepatosplenomegaly

Extremities Inguinal and Axillary adenopathy


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When to worry?

Age

Characteristics of the node

Location of the node Clinical setting associated with

lymphadenopathy


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Risk Factors to Keep in Mind Size Matters!!

In one series of 213 adults with unexplained LAN who

went on to biopsy

LN 1.5x1.5 (2.25 cm2) - 38% malignancy

Age Matters!! Age > 40, malignancy is more common

(Age >40 = 4% vs Age < 40 = 0.4%)

Location Matters!! Supraclavicular has the highest risk of Malignancy - est at

90% in patients >40 and 25% in ages < 40


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Characteristics of the node

ConsistencyHard/Firm vs Soft/Shotty; Fluctuant

Mobile vs Fixed/Matted

Tender vs Painless

Clearly demarcated

Size

When to worry1.5-2cm in size

Epitroclear nodes over 0.5cm; Inguinal over 1.5cm

Duration and Rate of Growth


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EXAMINATION OF A LUMP

Size

Consistency: Hodgkins rubbery

Tuberculosis matted

Metastatic cancer craggy

Calcified stony hard

Tenderness: infectious mononucleosis, dentalsepsis, tonsilitis

Fixation: malignancy


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Presentation of

lymphadenopathy

Unexplained

lymphadenopathy

3/4 presents with localized

1/4 present withgeneralized


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Posterior Cervical LAN - Mono


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y -Scrofula

Lymphatic spread ofM. tuberculosisas wellas atypical mycobacteria (M. scrofulaceum,

MAI)


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Mycobacterial Lymphadenitis


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TB abscessas part of immune reconstitution syndrome


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Diagnostic Tests

Fine needle aspiration biopsy (FNAB)

Computed tomography (CT)

Magnetic resonance imaging (MRI) Ultrasonography

Radionucleotide scanning


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Role of Ultrasound (Ahuja et al.

2005) No radiation exposure

Good for following the progress of an abscess

Differentiate Reactive vs Malignant nodes Reactive

0.5cm)

No echogenic hilus Cogaulative necrosis present

High resistive index with low blood flow Extracapsular spread

Sensitivity 95% and Specificity 83% for differentiating reactive vs metastaticlymph nodes


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Fine Needle Aspiration Biopsy

Standard of diagnosis

IndicationsAny neck mass that is not an obvious abscess

Persistence after a 2 week course of antibiotics

Small gauge needle Reduces bleeding

Seeding of tumornot a concern No contraindications (vascular ?)


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Fine Needle Aspiration Biopsy


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Differential Diagnosis

r t n


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a or at ogensHIV- related persistent generalized

lymphadenopathy (PGL)

Opportunistic infections tuberculous lymphadenitis, CMV,toxoplasmosis, infections with Nocardiaspecies, fungal infections(histoplasmosis, penicilliosis,cryptococcus, etc.)

Reactive Lymphadenopathy pyomyositis, pyogenic skin infections,ear, nose, and throat (ENT) infections

STIs syphilis, inguinal lymphadenopathy dueto donovanosis, chancroid orlymphogranuloma venereum (LGV)(see WHO or MSF guidelines)

Malignancies lymphoma, Kaposis sarcoma


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Lymphadenitis

Very common, especially within 1st decade

Tender node with signs of systemic infection

Directed antibiotic therapy with follow-up FNAB indications (pediatric)

Actively infectious condition with no response

Progressively enlarging

Solitary and asymmetric nodal mass

Supraclavicular mass (60% malignancy)

Persistent nodal mass without active infection


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Generalized Lymphadenopathy

Malignancylymphoma, leukemia, Kaposis sarcoma,metastases

AutoimmuneSLE, RA, Sjogrens syndrome, Stills

disease, Dermatomyositis InfectiousBrucellosis, Cat-scratch disease, CMV,

HIV, EBV, Rubella, Tuberculosis, Tularemia, TyphoidFever, Syphilis, viral hepatitis, Pharyngitis

OtherKawasakis disease, sarcoidosis, amyloidosis,lipid storage diseases, hyperthyroidism, necrotizinglymphadenitis, histiocytosis X, Castlemens disease


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Granulomatous lymphadenitis

TypicalM. tuberculosis

more common in adults Posterior triangle nodes

Rarely seen in our population

Usually responds to anti-TB medications May require excisional biopsy for further workup


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Drug Induced Lymphadenopathy

Medications Phenytoin

Pyrimethamine

Allopurinol

Phenylbutazone

Isoniazide Immunizations

Smallpox (historically)

Live attenuated MMR

DPT

Poliomyelitis

Typhoid fever

**Usually self limited and resolves with cessation of medication orwith time in the case of immunization induced LAD


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Inguinal LAN

STDs

Tinea infections (pedis/cruris)

Pelvic/Genital Malignancy

(squamous/melanoma)

Bubonic Plague? - was there an exposure?

Lymphoma


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Terima kasih


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Questions?

lymphadenopathy uniba 18-1-13

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