Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

Clinical approach to a Patient with Generalized Lymphadenopathy

No description
by

Ahmed Farag

on 17 June 2013

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Clinical approach to a Patient with Generalized Lymphadenopathy

Lymphatic System


Generalized
Lymphadenopathy

Lymphatic vessels
Lymph (Recycled Plasma)
Lymph Nodes
Lymphadenopathy
Definition :
nodes that are abnormal in either
SIZE , CONSISTENCY or NUMBER
Classification :
“Localized”
if only one area is involved.

“Generalized”
if lymph nodes are enlarged in
two or more non contiguous areas
History :
Etiology:
DD
Infections :
Infectious mononucleosis syndrome
(CMV, EB Virus)
HIV
Varicella-herpes zoster
Viral :
Fungal :
Collagen Vascular Causes
Common diseases
SLE
RA
Less common
Dermatomyositis
Still's
Neoplastic

Staph
Strept
TB & Leprosy
Salmonella
Brucellosis
Coccidioidomycosis
histoplasmosis
Parasitic :
Microfilariasis
trypanosomiasis.
Bacterial :
Spirochetal :
Syphilis
Toxoplasmosis
Hematologic
:
Hodgkin’s Lymphoma
Lymphsarcoma
Malignant Histiocytosis
Leukemias
(Lymphocytic , Myelocytic )
Metastatic :
Melanoma
Head & neck cancers
Lung Cancer
Breast Cancer
GIT cancers
Prostate Cancer
Renal carcinoma
kaposi's Sacoma
Neuroblastoma
Miscellaneous :
Serum Sickness
Sarcoidosis
Hyperthyroidism
Amyloidosis
(Lipid Storage)
*Niemann-Pick Disease
*Gaucher's Disease
Medications :
Phenytoin
Allopurinol
Carbamazepine
Captopril
Sulfonamides
Hydralazine
Diagnostic Approach
Age :
Symptoms :
Epidemiological Clues :
Exposure to Pets (Cats )
Travel to Endemic areas (East Africa & Mediterranean Kala- azar)
High risk sexual behaviors
IV drug abuse
Blood Transfusion
Occupation
Which Group affected first :
Medication History :
Examination :
Careful Palpation :
Size:
Site :
Consistency
Pain\Tenderness :
Mobility :
<1cm ... of no Significance
>2cm ... should be Evaluated
Freely mobile

Fixed

Matted
Search for Systemic illness
Hepato-Spleenomegally
Arthritis
Rash
Matted
TB
Stony Hard
Carcinoma
Rubbery
Lymphoma
Cystic- Soft
Cold abscess
Firm
Syphilis
Based on Findings
Diagnostic
Suggestive
Unexplained
Investigations :
Biopsy :
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
Cervical
group is first affected in many cases of Hodgkin’s
lymphoma
Duration :
The location of enlarged lymph nodes may suggest important clues to diagnosis.
ex. Post. Cervical ... Toxoplasmosis & Rubella
Supraclavicular
nodes enlargement is significant and frequently results from metastasis .
Right
: Lung , Esophageal , Mediastinum
Left

(Virchow's)
: GI - Pelvic
bilateral epitrochlear node enlargement is seen in Sarcoidosis and secondary Syphillis.
Benign as TB - Sarcoidosis


Pain is usually the result of an
inflammatory
process or suppuration, but pain may also result from hemorrhage into the necrotic center of a
malignant
node
malignant (metastatic carcinoma or lymphomas)
Hodgkin , TB, syphilis are disease of the young,
whereas secondary involvement of lymph node occurs in old age
Drug Hypersensitivity
Fever:

Night Fever in TB . Periodic fever in Filaria.
In Hodgkin’s disease intermittent bouts of recurrent fever
usually in a Localized case
Pharyngitis
Conjunctivitis
Upper Respiratory
HIV, SLE, Syphilis
Mononucleosis
CBC-ESR- CRP
EB virus - Toxoplasma IGM antibodies
Investigations for autoimmune
conditions :
LDH- Liver function tests
Ca - P& Uric acid.
Imaging :
Chest x-ray- CT scan- Mammograph & PET scan
RF-ANA
Persistent lymphadenopathy ( > 4 weeks) is indicative of chronic infection, collagen vascular disease or underlying malignancy.
as in Infections - Lymphoma
Indications for excision biopsy :
1-Patients with
non-diagnostic
Generalised Lymphadenopathy
2-Patients with
Localised persistent
lymphadenopathy, non-diagnostic initial studies and a high risk for malignancy.
Precautions :
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

4-Biopsies with
atypical lymphoid hyperplasia
should be considered
non-diagnostic
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.
Management :
in case of Localized with suggestive benign condition ... (observation for 4 weeks )
Mononucleosis-type syndromes

Fatigue, malaise, fever, atypical lymphocytosis

Epstein-Barr virus*

Splenomegaly in 50% of patients

Monospot, IgM EA or VCA

Toxoplasmosis*

80 to 90% of patients are asymptomatic

IgM toxoplasma antibody

Cytomegalovirus*

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

HIV antibody

Cat-scratch disease

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

Tuberculosis lymphadenitis*

Painless, matted cervical nodes

PPD, biopsy

Secondary syphilis*

Rash

RPR

Hepatitis B*

Fever, nausea, vomiting, icterus

Liver function tests, HBsAg

Lymphogranuloma venereum

Tender, matted inguinal nodes

Serology

Chancroid

Painful ulcer, painful inguinal nodes

Clinical criteria, culture

Lupus erythematosus*

Arthritis, rash, serositis, renal, neurologic, hematologic disorders

Clinical criteria, antinuclear antibodies, complement levels

Rheumatoid arthritis*

Arthritis

Clinical criteria, rheumatoid factor

Lymphoma*

Fever, night sweats, weight loss in 20 to 30% of patients

Biopsy

Leukemia*

Blood dyscrasias, bruising

Blood smear, bone marrow

Serum sickness*

Fever, malaise, arthralgia, urticaria; exposure to antisera or medications

Clinical criteria, complement assays

Sarcoidosis

Hilar nodes, skin lesions, dyspnea

Biopsy

Kawasaki disease*

Fever, conjunctivitis, rash, mucous membrane lesions

Clinical criteria
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
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
.
Prognosis
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.

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, toxoplasmosiss
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
lymphadenopathyInfections, cat-scratch disease, lymphoma, breast cancer, silicone implants, brucellosis, melanoma
Arm, thoracic wall, breast
Axillary
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
Differential Diagnosis
Evaluation of Suspected Causes of Lymphadenopathy
Biochemical tests:
Serological Examination :
Clinical Approach to
General lymphadenopathy
prepared by:
Rania Mo7ammed Ga3far
A7med Farag Ibrahim
Under the supervision of:
Dr.NASHWA SA3ED
Full transcript