Lymphadenopathy Most lymph nodes are not usually palpable in the newborn. With antigenic exposure, lymphoid tissue increases in volume so that the cervical, axillary, and inguinal nodes are often palpable during childhood



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Lymphadenopathy

 


Most lymph nodes are not usually palpable in the newborn.

With antigenic exposure, lymphoid tissue increases in volume so that the cervical, axillary, and inguinal nodes are often palpable during childhood.

They are not considered enlarged until their diameter exceeds 1 cm for cervical and axillary nodes and 1.5 cm for inguinal nodes.

Other lymph nodes usually are not palpable or visualized with plain radiographs.



DIAGNOSIS.

Lymph node enlargement is caused by proliferation of normal lymphoid elements or by infiltration with malignant or phagocytic cells.

In most patients, a careful history and a complete physical examination suggest the proper diagnosis.

Nonlymphoid masses (cervical rib, thyroglossal cyst, branchial cleft cyst or infected sinus, cystic hygroma, goiter, sternomastoid muscle tumor, thyroiditis, thyroid abscess, neurofibroma) occur frequently in the neck and less often in other areas.

Acutely infected nodes are usually tender. There may also be erythema and warmth of the overlying skin.

Fluctuance suggests abscess formation.

Tuberculous nodes may be matted.

With chronic infection, many of the above signs are not present.



Tumor-bearing nodes are usually firm and nontender, and may be matted or fixed to the skin or underlying structures.

Generalized adenopathy (enlargement of >2 noncontiguous node regions) is caused by systemic disease and is often accompanied by abnormal physical findings in other systems.

In contrast, regional adenopathy is most frequently the result of infection in the involved node and/or its drainage area .

When due to infectious agents other than bacteria, adenopathy may be characterized by atypical anatomic areas, a prolonged course, a draining sinus, lack of prior pyogenic infection, and unusual clues in the history (cat scratches, tuberculosis exposure, venereal disease).

A firm, fixed node should always raise the question of malignancy, regardless of the presence or absence of systemic symptoms or other abnormal physical findings.




Differential Diagnosis of Systemic Generalized Lymphadenopathy

INFANT

CHILD

ADOLESCENT

COMMON CAUSES

Syphilis

Viral infection

Viral infection

Toxoplasmosis

EBV

EBV

CMV

CMV

CMV

HIV

HIV

HIV

 

Toxoplasmosis

Toxoplasmosis

 

 

Syphilis

RARE CAUSES

Chagas disease (congenital)

Serum sickness

Serum sickness

Congenital leukemia

SLE, JRA

SLE, JRA

Congenital tuberculosis

Leukemia/lymphoma

Leukemia/lymphoma/Hodgkin disease

Reticuloendotheliosis

Tuberculosis

Lymphoproliferative disease

Lymphoproliferative disease

Measles

Tuberculosis

Metabolic storage disease

Sarcoidosis

Histoplasmosis

Histiocytic disorders

Fungal infection

Sarcoidosis

Plague

Fungal infection

Langerhan cell histiocytosis

Plague

Chronic granulomatous disease

Drug reaction

Sinus histiocytosis

Castleman disease

Drug reaction

 




EBV, Epstein-Barr virus; CMV, cytomegalovirus; HIV, human immunodeficiency virus; SLE, systemic lupus erythematosus; JRA, juvenile rheumatoid arthritis (as Still disease).







Sites of Local Lymphadenopathy and Associated Diseases

CERVICAL

  




Oropharyngeal infection (viral or group A streptococcal, staphylococcal)

  




Scalp infection

  




Mycobacterial lymphadenitis (tuberculosis and nontuberculous mycobacteria)

  




Viral infection (EBV, CMV, HHV-6)

  




Cat-scratch disease

  




Toxoplasmosis

  




Kawasaki disease

  




Thyroid disease

  




Kikuchi disease

  




Sinus histiocytosis

  




Autoimmune lymphoproliferative disease




ANTERIOR AURICULAR

  




Conjuctivitis

  




Other eye infection

  




Oculoglandular tularemia

  




Facial cellulitis




POSTERIOR AVRICULAN

  




Otitis media

  




Viral infection (especially rubella, parvovirus)




SUPRACLAVICULAR

  




Malignancy or infection in the mediastinum (right)

  




Metastatic malignancy from the abdomen (left)

  




Lymphoma

  




Tuberculosis




EPITROCHLEAR

  




Hand infection, arm infection[*]

  




Lymphoma[†]

  




Sarcoid

  




Syphilis




INGUINAL

  




Urinary tract infection

  




Venereal disease (especially syphilis or lymphogranuloma venereum)

  




Other perineal infections

  




Lower extremity suppurative infection

  




Plague




HILAR (NOT PALPABLE, FOUND ON CHEST RADIOGRAPH OR CT)

  




Tuberculosis[†]

  




Histoplasmosis[†]

  




Blastomycosis[†]

  




Coccidioidomycosis[†]

  




Leukemia/lymphoma[†]

  




Hodgkin disease[†]

  




Metastatic malignancy[*]

  




Sarcoidosis[†]

  




Castleman disease




AXILLARY

  




Cat-scratch disease

  




Arm or chest wall infection

  




Malignancy of chest wall

  




Leukemia/lymphoma

  




Brucellosis




ABDOMINAL

  




Malignancies

  




Mesenteric adenitis (measles, tuberculosis, Yersinia, group A streptococcus)







EBV, Epstein-Barr virus; CMV, cytomegalovirus; HHV-6, human herpesvirus 6; CT, computed tomography.




*

Unilateral.



Bilateral.


TREATMENT.

Evaluation and treatment of lymphadenopathy is guided by the probable etiologic factor, as determined from the history and physical examination.

Many patients with cervical adenopathy have a history compatible with viral infection and need no intervention.

If bacterial infection is suspected, antibiotic treatment covering at least streptococci and staphylococci is indicated.

Those who do not respond to oral antibiotics, as demonstrated by persistent swelling and fever, require IV antistaphylococcal antibiotics.

If there is no response in 1–2 days or if there are signs of airway obstruction or significant toxicity, CT or ultrasound of the neck should be obtained.

If pus is present, it may be aspirated, with CT or ultrasound guidance, or if it is extensive, it will require incision and drainage.

Gram stain and culture of the pus should be obtained.

Surgical drainage is required for an abscess.

The sizes of involved nodes should be documented before treatment.

Failure to decrease in size within 10–14 days also suggests the need for further evaluation.

This may include a complete blood cell count with differential; Epstein-Barr virus, cytomegalovirus, Toxoplasma, and cat scratch disease titers; antistreptolysin O or anti-DNAse serologic tests; tuberculin skin test; and chest radiograph.

If these are not diagnostic, consultation with an infectious disease or oncology specialist may be helpful.



Biopsy should be considered if there is :



  1. persistent or unexplained fever,

  2. weight loss,

  3. night sweats,

  4. hard nodes, or

  5. fixation of the nodes to surrounding tissues.

  6. an increase in size over baseline in 2 wk,

  7. no decrease in size in 4–6 wk, or

  8. no regression to “normal” in 8–12 wk, or

  9. if new signs and symptoms develop



Dr.Hayder al-Musawi


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