Approach to Lymphadenopathy

Dr Putra Hendra SpPD UNIBA

Definition

Approx 600 LN in body LAN = abnl size, number, consistency Generalized vs Local Peripheral (central LAN presents differently)

Lymph Nodes

Anatomy

Collection of lymphoid cells attached to both vascular and lymphatic systems Over 600 lymph nodes in the body
To provide optimal sites for the concentration of free or cellassociated antigens and recirculating lymphocytes sensitization of the immune response To allow contact between B-cells, T-cells and macrophages

Function

Lymphadenopathy - node greater than 1cm in size

Why do lymph nodes enlarge?

Increase in the number of benign lymphocytes and macrophages in response to antigens Infiltration of inflammatory cells in infection (lymphadenitis) In situ proliferation of malignant lymphocytes or macrophages Infiltration by metastatic malignant cells Infiltration of lymph nodes by metabolite laden macrophages (lipid storage diseases)

Definitions

Pathologic Lymph Node

>2cm in children is considered abnormal

< 2 weeks duration 2-6 weeks duration > 6 weeks duration

Acute Lymphadenopathy

Subacute Lymphadenopathy

Chronic Lymphadenopathy

Epidemiology

0.6% annual incidence of unexplained adenopathy in the general population 10% were referred to a subspecialist and 3.2 % required a biopsy and 1.1% had a malignancy

Epidemiology

Larsson et al. 38-45% of normal children have palpable cervical lymphadenopathy Park et al. 90% of children aged 4-8 have lymphadenopathy These masses can be mistaken for other local and systemic processes

Congenital Masses Malignancies Local presentation of systemic disease

Found by parents and caregivers and demand workup

Physical Exam

General Febrile or toxic appearing Skin Cellulitis, impetigo, rash HEENT Otitis, pharyngitis, teeth, and nasal cavity Neck Size Unilateral vs Bilateral Tender vs Nontender Mobile vs Fixed Hard vs Soft Lungs Consolidations suggesting TB Abdomen Hepatosplenomegaly Extremities Inguinal and Axillary adenopathy

When to worry?

Age Characteristics of the node Location of the node Clinical setting associated with lymphadenopathy

Risk Factors to Keep in Mind

Size Matters!!

In one series of 213 adults with unexplained LAN who went on to biopsy LN <1 cm - 0% malignancy LN 1-1.5 cm - 8% malignancy LN > 1.5x1.5 (2.25 cm2) - 38% malignancy Age > 40, malignancy is more common (Age >40 = 4% vs Age < 40 = 0.4%) Supraclavicular has the highest risk of Malignancy - est at 90% in patients >40 and 25% in ages < 40

Age Matters!!

Location Matters!!

Characteristics of the node

Consistency Hard/Firm vs Soft/Shotty; Fluctuant Mobile vs Fixed/Matted Tender vs Painless Clearly demarcated Size

When to worry 1.5-2cm in size Epitroclear nodes over 0.5cm; Inguinal over 1.5cm

Duration and Rate of Growth

EXAMINATION OF A LUMP

Size Consistency: Hodgkins rubbery

Tuberculosis matted Metastatic cancer craggy Calcified stony hard Tenderness: infectious mononucleosis, dental sepsis, tonsilitis Fixation: malignancy

Presentation of lymphadenopathy

Unexplained lymphadenopathy 3/4 presents with localized 1/4 present with generalized

Posterior Cervical LAN - Mono

Mycobacterial Adenitis Scrofula

Lymphatic spread of M. tuberculosis as well as atypical mycobacteria (M. scrofulaceum, MAI)

Mycobacterial Lymphadenitis

TB abscess
as part of immune reconstitution syndrome

Diagnostic Tests

Fine needle aspiration biopsy (FNAB) Computed tomography (CT) Magnetic resonance imaging (MRI) Ultrasonography Radionucleotide scanning

Role of Ultrasound (Ahuja et al. 2005)

No radiation exposure Good for following the progress of an abscess Differentiate Reactive vs Malignant nodes

Reactive

<1 cm Oval (S/L ratio <0.5cm) Normal hilar vascularity Low resistive index with high blood flow >1 cm Round (S/L ratio >0.5cm) No echogenic hilus Cogaulative necrosis present High resistive index with low blood flow Extracapsular spread

Malignant

Sensitivity 95% and Specificity 83% for differentiating reactive vs metastatic lymph nodes

Fine Needle Aspiration Biopsy

Standard of diagnosis Indications

Any neck mass that is not an obvious abscess Persistence after a 2 week course of antibiotics

Small gauge needle

Reduces bleeding Seeding of tumor not a concern

No contraindications (vascular ?)

Fine Needle Aspiration Biopsy

Differential Diagnosis

Major Pathogens
HIV- related
Opportunistic infections

persistent generalized lymphadenopathy (PGL)

tuberculous lymphadenitis, CMV, toxoplasmosis, infections with Nocardia species, fungal infections (histoplasmosis, penicilliosis, cryptococcus, etc.) pyomyositis, pyogenic skin infections, ear, nose, and throat (ENT) infections

Reactive Lymphadenopathy STIs

syphilis, inguinal lymphadenopathy due to donovanosis, chancroid or lymphogranuloma venereum (LGV) (see WHO or MSF guidelines) lymphoma, Kaposis sarcoma

Malignancies

Lymphadenitis

Very common, especially within 1st decade Tender node with signs of systemic infection Directed antibiotic therapy with follow-up FNAB indications (pediatric)

Actively infectious condition with no response Progressively enlarging Solitary and asymmetric nodal mass Supraclavicular mass (60% malignancy) Persistent nodal mass without active infection

Generalized Lymphadenopathy

Malignancy lymphoma, leukemia, Kaposis sarcoma, metastases Autoimmune SLE, RA, Sjogrens syndrome, Stills disease, Dermatomyositis Infectious Brucellosis, Cat-scratch disease, CMV, HIV, EBV, Rubella, Tuberculosis, Tularemia, Typhoid Fever, Syphilis, viral hepatitis, Pharyngitis Other Kawasakis disease, sarcoidosis, amyloidosis, lipid storage diseases, hyperthyroidism, necrotizing lymphadenitis, histiocytosis X, Castlemens disease

Granulomatous lymphadenitis

Typical M. tuberculosis
more common in adults Posterior triangle nodes Rarely seen in our population Usually responds to anti-TB medications May require excisional biopsy for further workup

Drug Induced Lymphadenopathy

Medications

Phenytoin Pyrimethamine Allopurinol Phenylbutazone Isoniazide

Smallpox (historically) Live attenuated MMR DPT Poliomyelitis Typhoid fever

Immunizations

**Usually self limited and resolves with cessation of medication or with time in the case of immunization induced LAD

Inguinal LAN

STDs Tinea infections (pedis/cruris) Pelvic/Genital Malignancy (squamous/melanoma) Bubonic Plague? - was there an exposure? Lymphoma

Terima kasih

Questions?