LIMFADENITIS AKUT DAN

KRONIS
RUDY AFRIANT
SUB-DIVISI HEMATOLOGI & ONKOLOGI MEDIK
BAGIAN ILMU PENYAKIT DALAM
FKUA/RSUP M. DJAMIL PADANG
2016
Objectives
Etiologies of infectious lymphadenitis

Clinical presentation

Differential diagnosis
Pathophysiology of Lymphadenopathy

Initial Infection
URI / Pharyngitis / Otitis Media / Odontogenic infection

Lymphatic drainage
Presentation to T cells
Proliferation of clonal cells
Release of cytokines leading to chemotaxis

Activation of B cells
Immunoglobulin release

Continued proliferation of immune response

 Pathophysiology Contd
Results of the Immune Response
Cellular Hyperplasia
Leukocyte Infiltration
Tissue Edema
Vasodilation and Capillary Leak
Tenderness due to capsule distension
DD
M

M
I
Approach to lymphadenitis
 History
Fever, malaise, anorexia, myalgias

Pain or tenderness of node

Sore Throat / URI / Toothache / Ear pain

Insect Bites

Exposure to animals

History of travel or exposure to TB

Immunizations

Medications
 Physical Exam
General
Febrile or toxic appearing
Skin
Cellulitis, impetigo, rash
ENT
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
 Laboratory Workup
CBC with Differential
ESR
Throat culture
Serology
EBV, CMV, Toxoplasmosis, Bartonella, Syphilis, HIV

PPD
LDH, uric acid
 Imaging Workup
CXR if malignancy sus.
To look for mediastinal
lymphadenopathy
Ultrasound
Abscess?
Benign vs. malignant
Sometimes CT/MRI
To evaluate for abscess
EKG/ECHO
If suspect Kawasaki Disease
Biopsy
FNA or Excisional
Suppurative Bacterial Lymphadenitis

Staphylococcus aureus and Group A Streptococcus

Anaerobes
Usually acute onset, fever, CBC
Management: antibiotics (which one?)
If not resolving or getting worse
Ultrasound and/or CT with contrast to evaluate for
phlegmon/abscess/infiltrate

FNA vs Surgical Excision if abscess is identified

Suppurative Lymphadenitis with
Overlying cellulitis
 Subacute Lymphadenitis
2-6 weeks
Usually no improvement with antibiotics
DD:
Atypical Mycobacteria
Cat Scratch disease
Toxoplasmosis
TB
 Atypical Mycobacteria
Leading cause of sub-acute disease
Species involved:
Mycobacterium avium-intrucellulare
Mycobacterium scrofulaceum

Develops over weeks to months

Lymph nodes may have violaceous skin over the node
No fever, normal behavior, no pain
Diagnosis: acid fast stain and culture, can take weeks. PCR.
Treatment: surgical excision of involved lymph nodes, some offer
antibiotics
Cat Scratch Disease
Bartonella Henselae
Exposure to cat bite or scratch
Can take up to 2 weeks to develop
Tender. Fever & malaise are mild and
present in <50% of patients

Diagnosis: serology or PCR

Treatment: none / antibiotics
Antibiotics always given to
immunocompromised patients to
prevent disseminated disease

**Other less common zoonotic causes are

tularemia, brucellosis, and anthracosis.
 Toxoplasmosis -
Toxoplasma gondii
Mechanism
Consumption of undercooked meat

Ingestion of oocytes from cat feces

Symptoms
Malaise, fever, sore throat, myalgias

90% have cervical lymphadenitis

Diagnosis: serology
Treatment: none. In pregnancy, congenital,
immunocompromised, retinitis: pyrimethamine
sulfadiazine
Kawasaki Disease
Diagnosis: Fever>5 days + 4/5:
Unilateral Cervical lymphadenopathy

Edema of palms and soles

Nonpurulent Conjunctivitis

Strawberry Tongue

Rash

Complications
Coronary artery aneurysms

Treatment
IVIG and Aspirin
 Kawasaki disease
Fever
Rash
Mucositis
Nonpurulant conjunctivitis
Cervical lymphadenopathy
Common under 4 years
Toxin of S, aureous implicated as a
possible etiology
Chronic form of lymphadenitis :
Mycobacterium tuberculosis
Atypical mycobacterium
Cat-scratch disease
Viral involvement
Toxoplasmosis
 Tuberculosis
lymphadenitis
Presenting(Scrofula)
Signs and Symptoms
Cervical nodes most commonly involved

Firm, discrete nodes

Fluctuant nodes

Skin breakdown, abscesses, chronic sinuses

healing and scarring
 Mycobacterium species
The most common cause of chronic
unilateral , suppurative cervical
lymphadenitis
Positve tuberculin test will differentiated
M. tuberculosis from atypical form .
Minimally tender , spontaneous rupture
Atypical form is rarely associated with
pulmonary disease
 Treatment

M. tuberculosis :
six month rifampin, isoniazide
,pyrazinamide

Atypical mycobacterium :
Surgical excision
 Summary
History and Physical exam
Further workup with serology, imaging, and biopsy with
resistant, subacute and chronic cases
Ultrasound is a useful to characterize and differentiate
reactive, suppurative, and malignant lymph nodes
Sometimes Biopsy
Why Men Cant Be
Babysitters