Lymphadenopathy
Continuity Clinic
Objectives
• Define lymphadenopathy
• Develop a systematic approach to the
evaluation and management of
lymphadenopathy
• Discuss the differential diagnosis of
localize and generalized lymphadenopathy
• Recognize worrisome features of
lymphadenopathy that should prompt a
referral for a biopsy
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Physiology & Anatomy
• Lymphatic system
– Open circulatory system
– Part of immune system
– Includes: lymph, lymphatic vessels, lymph
nodes, spleen, tonsils, adenoids, Peyer
patches, thymus
• Body has 600 lymph nodes
– Lymph drains through nodes as it heads to
right lymphatic duct and thoracic duct
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Lymphatic
System
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Physiology & Anatomy
• Lymph nodes are populated by:
– Macrophages, dendritic cells, B and T
lymphocytes
– B Lymphocytes
• Located in follicles and perfollicular area of lymph
nodes
– T Lymphocytes
• Interfollicular or paracortical area of lymph nodes
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Approach to Patient
• Lymphadenopathy – refers to lymph nodes that
are abnormal in size, number or consistency
• Consider:
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Age of Patient
Size of Nodes
Location of Nodes
Quality of Nodes
Localized or generalized
Time course of the lymphadenopathy
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Patient Age
• Not palpable in newborn
• Palpable nodes are the “norm” in the
cervical, axillary, and inguinal regions
throughout early childhood
• Children < 5 years old
– 44% palpable nodes at check up
– 64% palpable nodes at sick visits
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Patient Age
• The differential diagnosis is huge! But
consider age as you narrow it down. For
example:
• Preschool and early school age:
– URI, AOM, Conjunctivitis
• Teenagers
– Hodgkin lymphoma
– STDs
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Size of Lymph Nodes
• Rules of thumb:
– Axillary and cervical nodes < 1 cm
– Inguinal <1.5 cm
– Epitrochlear <0.5 cm
• Nodes tend to be larger in young children
• Odds of malignancy is higher in larger
nodes especially those > 2 cm
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Location of Lymph Nodes
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Node Groups
Occipital
Postauriclular
Preauricular
Parotid
Submandibular
Submental
Superficial cervical
Deep cervical
Supraclavicular
Deltopectoral
Axillary
Epitrochlear
Inguinal
Popliteal
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Region Drained
Posterior Scalp
Temporal & parietal scalp
Scalp, ear canal, conjunctiva
Scalp, midface, ear canal and ear, parotid
Cheek, nose, lips, tongue, subman. gland
Lower lip, floor of mouth
Lower larynx, lower ear canal, parotid
Tonsils, adenoids, scalp, larynx, sinuses
Mediastinum, lungs, abdomen
Arm
Arm, breast, thorax, neck
Medial arm below elbow
Lower extremities, genitalia, abdomen
Lower leg
Quality of Lymph Nodes
• Painful
– Usually infection, especially if erythema, warmth, or
fluctance
– Malignancy can cause node tenderness because of
hemorrhage into node and stretching of capsule
• Hard
– Found in cancers because of fibrosis
• Nonmobile
– Become fixed from invasive cancers of inflammation
in tissue surrounding nodes (ie TB or sarcoidosis)
• SOFT, COMPRESSIBLE = NORMAL
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Localized vs. Generalized
Lymphadenopathy
• Localized
– Most commonly cervical then inguinal
– Can be infection/inflammation in the area
drained by that node or infection of node itself
• Generalized
– Systemic disease
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Localized Lymphadenopathy
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Differential Diagnosis - Infection
• Bacterial
– Localized: Staph aureus, GAS, cat-scratch, tularemia, diphtheria
– Generalized : Brucellosis, leptospirosis, typhoid
• Viral
– EBV, CMV, HSV, HIV, Hep B, Measles, Mumps, Rubella, Dengue
Fever
• Myocobacterial
– TB, Atypical mycobacteria
• Fungal
– Coccidiomycosis, Cryptococcosis, Histoplasmosis
• Protozoal
– Toxoplamosis, Leishmaniasis
• Spirochetal
– Lyme disease, symphilis
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Differential Diagnosis - Other
• Malignancy
– leukemia, lymphoma, metastasis from solid tumor
• Immunologic
– SLE, serum sickness, Langerhans cell histiocytosis,
RA, Drug Reaction, dermatomyositis, CGD
• Endocrine
– Addison disease, hypothyroidism
• Other
– Amyloidosis, Kawasaki disease, Sarcoidosis, ChurgStrauss syndrome, Kikuchi disease, Castleman
disease
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Time Course of Lymphadenopathy
• When to biopsy
– Many advocate biopsy of concerning nodes that have
not decreased after 4-6 weeks or have not normalized
in 8-12 weeks
– Lymph nodes present for long time are not likely to be
malignant except for Hodgkins
• Exposure
– medications, animals, uncooked meats,
unpasteurized milk
• Associated constitutional symptoms
– Fever, night sweats, weight loss, pruritus, arthralgias,
fatigue
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Specific Causes of
Lymphadenopathy
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Lymphadenitis
• Lymphadenitis – enlarged, inflamed, tender lymph nodes
• Organisms:
– Staph aureus, GAS (80%)
• Usually submandibular
– Southwest US
• Yersinia pestis = Bubonic plague
– Bartonella henselae = cat scratch
– TB and atypical mycobacteria (M. avium and M. scrofulaceum)
• Management
– Culture drainage or of pharyngeal exudate
– Treatment
• 1st/2nd generation cephalosporin or dicloxacillin
• Clindamycin or Augmentin if anaerobe suspected (oral)
– Ultrasound to determine if abscess
– I&D indicated if abscess present
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Infectious Mononucleosis
• Symptoms
– fever, pharyngitis, lymphadenopathy (symmetric
involvement of posterior cervical nodes)
• EBV, CMV, toxoplasmosis, Streptococcus, hep
B, HIV
• Testing
– Monospot test (heterophile antibody)
• High false negative in < 4 YO and early illness
– Specific serologic tests
• Elevated immunoglobulin M titer to viral capsid antigen (IgmVCA) indicates acute infection
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Diagnostic Testing to Consider
• Blood
– CBC, ESR, LDH
– Specific Serologic testing (EBV, CMV,
Bartonella)
• Tuberculin Skin Testing
• Chest X-ray
• Biopsy
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