Assessment of lymphadenopathy Flashcards
(31 cards)
What is lymphadenopathy?
Lymphadenopathy is defined as lymph nodes that are abnormal in size, consistency or number.
The extent of lymphadenopathy is defined as localised, regional or generalised.
What should physician pay close attention to in regards to lymphadenopathy?
Size Location Consistency Number of enlarged lymph nodes Patient's age Duration of lymphadenopathy Associated symptoms Generalised or localised Mobility of lymph nodes Skin lesions or neoplasms
Causes of lymphadenopathy
CHICAGO Cancer (malignancy) Hypersensitivity syndromes Infections Collagen vascular disease Atypical lymphoproliferative disorders Granulomatous disease Other causes (miscellaneous).
‘C’ in Chicago
More commonly found in older patients, with carcinomas frequently diagnosed in patients who are 50 years and older.
Haematological malignancies, HL and NHL, and CLL often present with constitutional or B symptoms including fever, rash, and weight loss, and also with splenomegaly.
Hx of prior cancer should prompt an evaluation for possible recurrent cancer or metastatic disease.
‘H’ in Chicago
-The following hypersensitivity syndromes may be associated with reactive lymphadenopathy: Graft-versus-host disease Serum sickness. -Drug-associated lymphadenopathy often occurs several months after initiation of the drug and resolves within a few weeks of its discontinuation. Medications that can cause lymphadenopathy include: Allopurinol Atenolol Captopril Carbamazepine Hydralazine Penicillins Phenytoin Quinidine Trimethoprim/sulfamethoxazole
‘I’ in Chicago
Infection is a common underlying aetiology of lymphadenopathy and is especially seen in young patients, in whom infectious mononucleosis should initially be ruled out.
Questions to ask a person with symptoms indicative of an infection
There may be localising symptoms and signs suggestive of infection such as skin ulceration, sore throat, or insect bites
There may be constitutional symptoms such as fever or night sweats
There may be a history of travel (e.g., to southwest US, India, Asia, South America, West Africa)
Animal contact (e.g., cats)
Eating undercooked meat
High-risk sexual behaviours, or intravenous drug use or transfusion.
Infections presenting with lymphadenopathy
TB and EBV are important ones.
Viral: infectious mononucleosis (Epstein-Barr virus), cytomegalovirus, hepatitis B, hepatitis C, adenovirus, herpes zoster, herpes simplex, HIV, human T-lymphotropic virus 1, mumps, measles, rubella
Bacterial: staphylococcal and streptococcal infections (particularly pharyngitis), cat scratch disease, tuberculosis, atypical mycobacteria (such as mycobacterium avium-intracellulare), primary and secondary syphilis, tularemia, brucellosis, chancroid, leptospirosis
Fungal: histoplasmosis, coccidioidomycosis, cryptococcosis
Chlamydial: lymphogranuloma venereum
Parasitic: toxoplasmosis, leishmaniasis
Rickettsial: Rocky Mountain spotted fever.
‘C’ in Chicago
Lymphadenopathy in the presence of arthralgias, myalgias, morning stiffness or rash should raise a concern for the presence of an underlying collagen vascular disease:
Systemic lupus erythematosus: lymphadenopathy is seen in 50% of patients
Rheumatoid arthritis
Dermatomyositis
Sjogren’s syndrome.
‘A’ in Chicago
Lymphadenopathy can be a presenting symptom of a number of rare systemic diseases of unknown aetiology that also present with systemic symptoms including fever and hepatosplenomegaly:
Castleman’s disease
Kikuchi’s disease (histiocytic necrotising lymphadenitis)
Inflammatory pseudotumour
Progressive transformation of germinal centres
Rosai-Dorfman disease (sinus histiocytosis with massive lymphadenopathy)
Kawasaki’s disease.
‘G’ in Chicago
Granulomas represent a special type of chronic inflammation or delayed-type hypersensitivity reaction in which macrophages and lymphocytes predominate, and which may feature macrophage giant cells.
- Sarcoidosis features non-caseating granulomas in peripheral and mediastinal lymph nodes.
- Crohn’s disease and granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis)
- Mycobacterial infections, including infection with Mycobacterium tuberculosis, Mycobacterium leprae, and atypical mycobacterial infections such as Mycobacterium avium-intracellulare.
What is the urgent consideration in a patient presenting with lymphadenopathy?
Superior vena cava syndrome- this occurs when the superior vena cava becomes occluded or compressed.
Lymphoma and lung cancer are common malignancies associated with superior vena cava syndrome (SVCS), although benign conditions may also result in this syndrome.
In most cases, SVCS is not a medical emergency unless neurological symptoms are present.
A biopsy should be obtained prior to the initiation of therapy. Biopsies can often be obtained from more accessible, peripheral lymph node sites. If no peripheral lymph nodes can be sampled, mediastinoscopy may be required for diagnosis.
Differentials for a patient presenting with lymphadenopathy
EPV HIV CMV Shingles Adenovirus NHL HL CLL Metastatic solid tumour GvHD
History of a patient with lymphadenopathy
Age of the patient Symptoms of infection Symptoms of metastatic malignancy Constitutional or B symptoms Epidemiological clues Medication history Duration of lymphadenopathy
Symptoms of an infection in lymphadenopathy
These include pharyngitis, conjunctivitis, skin ulceration, localised tenderness, genital sores or discharge, fever, and night sweats
Symptoms of metastatic malignancy in lymphadenopathy
Constitutional symptoms of malignancy such as weight loss and night sweats may be associated with localised symptoms such as difficulty in swallowing, hoarseness and pain (in head and neck cancer), cough, and haemoptysis (in lung cancer)
What are the B symptoms?
Fever, night sweats, and/or unexplained weight loss greater than 10% of body weight over 6 months are concerning for lymphoma.
arthralgias, rash, and myalgias suggest the presence of a collagen vascular disease
What are epidemiological clues associated with lymphadenopathy?
Exposure to pets, occupational exposures, recent travel, or high-risk behaviours may suggest specific disorders
Medication history suggestive of lymphadenopathy
Drug hypersensitivity (e.g., to phenytoin) is a common cause of lymphadenopathy
Duration of lymphadenopathy
Persistent lymphadenopathy (more than 4 weeks) is indicative of chronic infection, collagen vascular disease, or underlying malignancy Localised lymphadenopathy of brief duration often accompanies some infections (e.g., infectious mononucleosis and bacterial pharyngitis)
Assessment of lymph nodes in lymphadenopathy
The most important physical examination findings are lymph node size, consistency, mobility, and distribution
Abnormalities in lymph node size
As a general rule, lymph nodes measuring less than 1 cm are rarely of clinical significance. In contrast, lymph nodes greater than 2 cm that is persistent for more than 4 weeks should be thoroughly evaluated.
Abnormalities in lymph node consistency
in general, lymph node consistency should not be used to distinguish between malignant and benign aetiologies. However, rock-hard nodes are seen more commonly with malignancies, whereas tender nodes often suggest an inflammatory disorder
Abnormalities in lymph node mobility
Fixed or matted nodes suggest metastatic carcinoma, whereas freely movable nodes may occur in infections, collagen vascular disease, and lymphoma.
Evaluation of the mobility of supraclavicular nodes is enhanced by having the patient perform a Valsalva manoeuvre.
