Lymphadenopathy
Surapon Wiangnon
References
• Ferrer R. Lymphadenopathy: Differential Diagnosis and
Evaluation. American Family Physician October 15, 1998
• Nelson Textbook of Pediatrics. 17th edition. 2004
• Oski’s Pediatrics, Principles & Practice. 2006
General principles
• usually a result of benign infectious causes.
• Mostly diagnosed on the basis of a careful
history and physical examination.
• Localized adenopathy should prompt a search
for an adjacent precipitating lesion.
• In general, cervical, axillary lymph nodes greater
than 1 cm and inguinal > 1.5 cm in diameter are
considered to be abnormal.
• Generalized adenopathy should always prompt
further clinical investigation.
Definition
• Lymphadenopathy refers to nodes that are
abnormal in either size, consistency or number.
• "generalized" if lymph nodes are enlarged in two
or more noncontiguous areas
• "localized" if only one area is involved.
• Generalized lymphadenopathy almost always
indicates the presence of a significant systemic
disease.
Lymphoid type
Epidemiology
• Population-based study (Dutch): 10% of patients
with unexplained adenopathy required referral to a
subspecialist, and only 1 percent had a malignancy
• In primary care settings, patients 40 years of age
and older with unexplained lymphadenopathy have
about a 4 % risk of cancer versus a 0.4% risk in
patients younger than age 40.
(Fijten GH, Blijham GH. Unexplained lymphadenopathy in family practice. An evaluation of the
probability of malignant causes and the effectiveness of physicians' workup. J Fam Pract
1988;27: 373-6)
Evaluation of possible
adenopathy
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Is the swelling a lymph node?
Is the node enlarged?
What are the characteristics of the node?
Is the adenopathy local or genralized?
Physical examination
Five characteristics should be noted and described:
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•
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Size. normal if < 1 cm in diameter;
Abnormal: epitrochlear nodes > 0.5 cm
inguinal nodes > 1.5 cm
Pain/Tenderness. inflammatory process or suppuration, hemorrhage into the
necrotic center of a malignant node.
Consistency. Stony-hard nodes: cancer, usually metastatic.
Very firm, rubbery nodes: lymphoma.
Softer nodes: infections or inflammatory conditions.
Suppurant nodes may be fluctuant.
"shotty" (small nodes that feel like buckshot under the skin)
cervical nodes of children with viral illnesses.
Matting. benign (e.g., tuberculosis, sarcoidosis or lymphogranuloma venereum)
malignant (e.g., metastatic carcinoma or lymphomas).
Location.
Lymph Node Groups: Location, Lymphatic Drainage
and Selected Differential Diagnosis
Location
Lymphatic drainage
Causes
Submandibular
Tongue, submaxillary gland,
lips and mouth,
conjunctivae
Infections of head, neck,
sinuses, ears, eyes, scalp,
pharynx
Submental
Lower lip, floor of mouth, tip
of tongue, skin of cheek
Mononucleosis syndromes,
Epstein-Barr virus,
cytomegalovirus,
toxoplasmosis
Jugular
Tongue , tonsil, pinna,
parotid
Pharyngitis organisms,
rubella
Posterior cervical
Scalp and neck, skin of
arms and pectorals, thorax,
cervical and axillary nodes
Tuberculosis, lymphoma,
head and neck malignancy
Suboccipital
Scalp and head
Local infection
Lymph Node Groups: Location, Lymphatic Drainage
and Selected Differential Diagnosis
Location
Lymphatic drainage
Causes
Postauricular
External auditory meatus,
pinna, scalp
Local infection
Preauricular
Eyelids and conjunctivae,
temporal region, pinna
External auditory canal
Right supraclavicular node
Mediastinum, lungs,
esophagus
Lung, retroperitoneal or
gastrointestinal cancer
Left supraclavicular node
Thorax, abdomen via
thoracic duct
Lymphoma, thoracic or
retroperitoneal cancer,
bacterial or fungal infection
Axillary
Arm, thoracic wall, breast
Infections, cat-scratch
disease, lymphoma, breast
cancer, brucellosis,
melanoma
Lymph Node Groups: Location, Lymphatic Drainage
and Selected Differential Diagnosis
Location
Lymphatic drainage
Causes
Epitrochlear
Ulnar aspect of forearm
and hand
Infections, lymphoma,
sarcoidosis, tularemia,
secondary syphilis
Inguinal
Penis, scrotum, vulva,
vagina, perineum, gluteal
region, lower abdominal
wall, lower anal canal
Infections of the leg or
foot, STDs (e.g., herpes
simplex virus,
gonococcal infection,
syphilis, chancroid,
granuloma inguinale,
lymphogranuloma
venereum), lymphoma,
pelvic malignancy,
bubonic plague
Common causes of generalized
lymphadenopathy
• Infections: Typhoid fever, TB, AIDS, mononucleosis, CMV,
rubella, varicella, rubeola, histoplasmosis, toxoplasmosis
• Autoimmune diseases: RA, SLE, dermatomyositis
• Malignancies:
primary: HD, NHL, histiocytic disorders,
metastatic: leukemia, NB, RMS
• Lipid storage diseases: Gaucher, Niemann-Pick
• Drug reactions
Medications That May Cause
Lymphadenopathy
Allopurinol
Atenolol
Captopril
Carbamazepine
Cephalosporins
Gold
Hydralazine
Penicillin
Phenytoin
Primidone
Pyrimethamine
Quinidine
Sulfonamides
Sulindac
. Pangalis GA, Vassilakopoulos TP, Boussiotis VA, Fessas P.
Clinical approach to lymphadenopathy. Semin Oncol 1993; 20:570-82
Common causes of regional node
enlargement
• Occipital: roseola, rubella, scalp infections
• Preauricular: cat-scrath disease, eye
infections
• cervical: Streptococcal/staphyllococcal
adenitis or tonsillitis, mononucleosis,
toxoplasmosis, maligancies, Kawasaki
disease
• Submaxillary: HD, NHL, tuberculosis,
histoplasmosis
Common causes of regional node
enlargement
• Axillary: infections of arm/chest wall, catscratch disease, malignancies
• Mediastinal: maligancies (T-cell
leukemia/lymphoma, thymoma, teratoma),
TB
• Abdominal: malignancies, mesenteric
adenitis
• Illioinguinal: infections of leg, groin
Indication for biopsy
• increase in size over baseline in 2 weeks
• no decease in size in 4-6 weeks
• no regression to normal in 8-12 weeks
• development of new signs and symptoms
Caution!
• Biopsy should be avoided in patients with
probable viral illness because lymph node
pathology in these patients may sometimes
simulate lymphoma and lead to a falsepositive diagnosis of malignancy.
• Fine-needle aspiration is occasionally
considered an alternative to excisional
biopsy but is often unhelpful.
Final Comment
• In most patients, lymphadenopathy has a readily diagnosable
infectious cause.
• A diagnosis of less obvious causes can often be made after
considering the patient's age, the duration of the lymphadenopathy
and whether localizing signs or symptoms, constitutional signs or
epidemiologic clues are present.
• When the cause of the lymphadenopathy remains unexplained, a
10-14 day (3-4-week) observation period is appropriate when the
clinical setting indicates a high probability of benign disease.