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Clinical approach to a Patient with Generalized Lymphadenopathy
Transcript of Clinical approach to a Patient with Generalized Lymphadenopathy
Lymph (Recycled Plasma)
nodes that are abnormal in either
SIZE , CONSISTENCY or NUMBER
if only one area is involved.
if lymph nodes are enlarged in
two or more non contiguous areas
Infectious mononucleosis syndrome
(CMV, EB Virus)
Collagen Vascular Causes
TB & Leprosy
(Lymphocytic , Myelocytic )
Head & neck cancers
Epidemiological Clues :
Exposure to Pets (Cats )
Travel to Endemic areas (East Africa & Mediterranean Kala- azar)
High risk sexual behaviors
IV drug abuse
Which Group affected first :
Medication History :
Careful Palpation :
<1cm ... of no Significance
>2cm ... should be Evaluated
Search for Systemic illness
Based on Findings
20 L/day of blood Filtered through capillaries
17 liters of the filtered plasma get reabsorbed directly into the blood vessels, while the remaining 3 L are left behind in the interstitial fluid.
in childhood .. LN enlargement is a universal finding
nearly all children under 12 years have palpable cervical, axillary and inguinal nodes.
in Adults ... Inguinal LN enlargement is commonplace due to repeated minor Injuries to the lower extremities .
but sometimes single or multiple SMALLER nodes may warrant Investigation .
it may give some clue to the diagnosis for example
group is first affected in many cases of Hodgkin’s
The location of enlarged lymph nodes may suggest important clues to diagnosis.
ex. Post. Cervical ... Toxoplasmosis & Rubella
nodes enlargement is significant and frequently results from metastasis .
: Lung , Esophageal , Mediastinum
: GI - Pelvic
bilateral epitrochlear node enlargement is seen in Sarcoidosis and secondary Syphillis.
Benign as TB - Sarcoidosis
Pain is usually the result of an
process or suppuration, but pain may also result from hemorrhage into the necrotic center of a
malignant (metastatic carcinoma or lymphomas)
Hodgkin , TB, syphilis are disease of the young,
whereas secondary involvement of lymph node occurs in old age
Night Fever in TB . Periodic fever in Filaria.
In Hodgkin’s disease intermittent bouts of recurrent fever
usually in a Localized case
HIV, SLE, Syphilis
EB virus - Toxoplasma IGM antibodies
Investigations for autoimmune
LDH- Liver function tests
Ca - P& Uric acid.
Chest x-ray- CT scan- Mammograph & PET scan
Persistent lymphadenopathy ( > 4 weeks) is indicative of chronic infection, collagen vascular disease or underlying malignancy.
as in Infections - Lymphoma
Indications for excision biopsy :
lymphadenopathy, non-diagnostic initial studies and a high risk for malignancy.
1-Biopsies should be obtained at the most abnormal or largest lymph node site
2-Inguinal node biopsy should be avoided
3-Empiric therapy with corticosteroids or antibiotics should be avoided in patients with non-diagnostic work-ups as they may confound the results of a lymph node biopsy due to their lympholytic effect
atypical lymphoid hyperplasia
should be considered
rather than negative for a malignancy, and these patients should be carefully followed and an additional lymph node biopsy strongly considered
5-For patients with high risk malignancy, an unrevealing lymph node biopsy should be considered non-diagnostic rather than negative for malignancy, and further work-up should be pursued.
in case of Localized with suggestive benign condition ... (observation for 4 weeks )
Fatigue, malaise, fever, atypical lymphocytosis
Splenomegaly in 50% of patients
Monospot, IgM EA or VCA
80 to 90% of patients are asymptomatic
IgM toxoplasma antibody
Often mild symptoms; patients may have hepatitis
IgM CMV antibody, viral culture of urine or blood
Initial stages of HIV infection*
“Flu-like” illness, rash
Fever in one third of patients; cervical or axillary nodes
Usually clinical criteria; biopsy if necessary
Pharyngitis due to group A streptococcus, gonococcus
Fever, pharyngeal exudates, cervical nodes
Throat culture on appropriate medium
Painless, matted cervical nodes
Fever, nausea, vomiting, icterus
Liver function tests, HBsAg
Tender, matted inguinal nodes
Painful ulcer, painful inguinal nodes
Clinical criteria, culture
Arthritis, rash, serositis, renal, neurologic, hematologic disorders
Clinical criteria, antinuclear antibodies, complement levels
Clinical criteria, rheumatoid factor
Fever, night sweats, weight loss in 20 to 30% of patients
Blood dyscrasias, bruising
Blood smear, bone marrow
Fever, malaise, arthralgia, urticaria; exposure to antisera or medications
Clinical criteria, complement assays
Hilar nodes, skin lesions, dyspnea
Fever, conjunctivitis, rash, mucous membrane lesions
Once swollen lymph nodes are identified
First, the cause of the swelling has to be identified. treatment of the cause will usually result in a resolution of the lymphadenopathy.
These can include:
antibiotics to treat any bacterial infections
antivirals to treat any viral illness
a lymph node biopsy made be needed to identify cancer. If cancer is diagnosed, chemotherapy will be used to treat the cancer and reduce the lymph node swelling.
depending on the cause, sometimes the lymphadenopathy is monitored without treatment and eventually resolves on it’s own.
Complications are usually related to the specific underlying disorder causing the lymphadenopathy; however, the lymphadenopathy itself can cause potentially serious complications.
•Mediastinal adenopathy can result in several potentially life-threatening complications.
Recognition of these complications is important because mediastinal adenopathy cannot be directly assessed clinically and therefore may be easily missed.
•Mediastinal adenopathy can cause superior vena cava syndrome with obstruction of blood flow;bronchial or tracheal obstruction with cough, wheezing, and ultimately respiratory tract obstruction (which can be life threatening); and dysphagia from esophageal compression.Occasionally, erosion of a node into a bronchus or trachea can result in hemoptysis.
•When the diagnosis of an underlying malignancy is missed, serious metabolic complications can occur,these include uric acid nephropathy, hyperkalemia, hypercalcemia, hypocalcemia, hyperphosphatemia and acid renal failure.
•Abdominal adenopathy can cause abdominal or back pain, constipation, and urinary frequency.
Intestinal obstruction caused by intussusception can be life threatening
The prognosis of lymphadenopathy almost entirely depends on the underlying etiology. Patients with specific complications, such as superior vena cava syndrome, are at risk unless this specific complication is managed.
Their prognosis is dependent on the management of the neoplastic process resulting in superior vena cava syndrome.
Prevalence of lymphoma
Lymphoma represents 10% of the total cancer cases in Egypt, as it is the second species prevalent among women after breast cancer, and the third among the men after the bladder and liver cancer, as reported by a recent study, at a time when warnedWorld Health Organization (WHO) of the high rate of infection in developing countries over the next ten years
Studies indicate that the factors that increase the chances of HIV infection hepatitis C, pesticides and some hair dyes.
Tongue, submaxillary gland, lips and mouth, conjunctivae
Infections of head,
neck, sinuses, ears,
eyes, scalp, pharynx
Lower lip, floor of mouth, tip of tongue, skin of cheek
Mononucleosis syndromes, Epstein-Barr virus, cytomegalovirus, toxoplasmosiss
Tongue, tonsil, pinna, parotid
Pharyngitis organisms, rubella
Scalp and neck, skin of arms and pectorals, thorax, cervical and axillary nodes
Tuberculosis, lymphoma, head and neck malignancy
Scalp and head
lymphadenopathyInfections, cat-scratch disease, lymphoma, breast cancer, silicone implants, brucellosis, melanoma
Arm, thoracic wall, breast
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
Evaluation of Suspected Causes of Lymphadenopathy
Serological Examination :
Clinical Approach to
Rania Mo7ammed Ga3far
A7med Farag Ibrahim
Under the supervision of: