Lymphadenopathy
Lymphadenopathy: Excerpt from The 5-Minute Pediatric Consult
Hans B. Kersten, MD
Lymphadenopathy - BASICS
Lymphadenopathy - description
- Term used to describe 1 or more enlarged lymph nodes >10 mm in diameter (for inguinal nodes, >15 mm; for epitrochlear nodes, >5 mm)
- Any palpable supraclavicular, popliteal, or iliac lymph node considered abnormal
- Normal lymph nodes: Generally <10 mm
- Lymph nodes often palpable in normal, healthy children. They are present from birth, peak in size between 8 and 12 years of age, and then regress during adolescence.
- Lymph nodes drain contiguous areas:
- Cervical nodes drain head and neck area.
- Axillary nodes drain arm, thorax, and breast.
- Epitrochlear nodes drain forearm and hand.
- Inguinal nodes drain leg and groin.
- Supraclavicular nodes drain thorax and abdomen.
Lymphadenopathy - epidemiology
Lymphadenopathy - incidence
Difficult to determine because it depends on the underlying process that causes lymph node enlargement.
Lymphadenopathy - prevalence
Palpable nodes present in 5–25% of newborns (cervical, axillary, inguinal) and in >50% of older children (all areas except epitrochlear, supraclavicular, and popliteal)
Lymphadenopathy - pathophysiology
- Lymphatic flow from adjacent nodes or inoculation site brings micro-organisms to lymph nodes.
- Lymph node enlargement may occur via any of the following mechanisms:
- Nodal cells may replicate in response to antigenic stimulation (e.g., Kawasaki disease) or malignant transformation (e.g., lymphoma).
- Large number of reactive cells from outside node (e.g., neutrophils or metastatic cells) may enter node.
- Foreign material may be deposited into node by lipid-laden histiocytes (e.g., lipid storage diseases).
- Vascular engorgement and edema may occur secondary to local cytokine release.
- Suppuration secondary to tissue necrosis (e.g., Mycobacterium tuberculosis)
- Many systemic infections (e.g., HIV) cause hepatic or splenic enlargement in addition to generalized lymphadenopathy.
Lymphadenopathy - etiology
Usually determined by performing a thorough history and physical examination
Lymphadenopathy - associated conditions
Many systemic infections (e.g., HIV) cause hepatic or splenic enlargement in addition to generalized lymphadenopathy.
Lymphadenopathy - DIAGNOSIS
Lymphadenopathy - signs & symptoms
- Localized lymphadenopathy: Involves enlarged nodes in any 1 region
- Generalized lymphadenopathy: Involves 2 or more noncontiguous regions secondary to a systemic process, such as EBV infection.
- Supraclavicular nodes seen with malignancy: Right-sided supraclavicular node is associated with mediastinal malignancy; left-sided node suggests abdominal malignancy.
Lymphadenopathy - history
Should focus on the following:
- Preceding symptoms (e.g., upper respiratory symptoms preceding cervical lymphadenopathy)
- Localizing signs or symptoms: Stomatitis may be associated with mandibular nodes, for example
- Duration: Days or weeks
- Constitutional or associated symptoms (e.g., fever, weight loss, or night sweats)
- Exposures: Cat exposure (catscratch disease), uncooked meat (toxoplasmosis), tick bite (Lyme disease)
- Medications (e.g., phenytoin or isoniazid)
- Travel to or residence in an endemic area should raise suspicion for tuberculosis, Lyme disease.
Lymphadenopathy - physical exam
- Complete physical exam imperative to look for signs of systemic disease such as skin findings, ocular findings, or hepatosplenomegaly
- If localized lymphadenopathy suspected, examine the area that the lymph node drains for pathology. For example, an arm papule may be associated with axillary lymphadenopathy in catscratch disease.
- Cervical, axillary, and inguinal nodes, as well as liver and spleen, must be palpated to help determine if signs of systemic disease or infection are present.
- Characterize nodes. Be sure to note:
- Location: Be as exact as possible (see above).
- Size: Specify dimensions.
- Consistency: Soft, firm, solid, cystic, fluctuant, rubbery. Firm, rubbery nodes may be associated with lymphomas, while soft nodes are generally palpated with reactive lymphadenopathy.
- Fixation: Normally freely mobile; infection or malignancy may cause adherence to surrounding tissues or nodes.
- Tenderness: Suggests inflammation
Lymphadenopathy - tests
Lymphadenopathy - lab
Consider the following tests if 1 or more nodes is persistently enlarged, has increased in size, has changed in consistency or mobility, or if systemic symptoms are present:
- CBC: Consider with generalized lymphadenopathy, or if malignancy is in differential diagnosis (ddx)
- Purified protein derivative (PPD) testing: Consider with persistently enlarged node (2– 4 weeks) or travel to areas where tuberculosis is endemic
- ESR: Increased with infection or inflammation
- Throat culture: If concern for group A โ–hemolytic streptococcal (GAS) pharyngitis
- EBV/Cytomegalovirus (CMV) titers: Consider with persistent generalized adenopathy
- Bartonella henselae titers: Consider with persistently enlarged unilateral node and/or history of cat exposure
- Toxoplasma gondii titers: Consider with generalized lymphadenopathy and exposure to undercooked or raw meat
- HIV testing: Consider with persistent generalized lymphadenopathy and failure to thrive.
- Lactate dehydrogenase (LDH), uric acid and liver enzymes: Consider if history and physical exam raise concern for malignancy
- Rapid plasma reagin (RPR): Consider with rash and generalized lymphadenopathy or other signs of syphilis
- Antinuclear antibody (ANA): if persistent generalized lymphadenopathy and other signs of systemic disease to rule out systemic lupus erythematosus (SLE)
Lymphadenopathy - imaging
- Chest radiograph: Helpful with supraclavicular nodes, systemic symptoms, or if positive PPD
- Ultrasound: May help differentiate cystic from solid masses
- CAT scan: May help delineate anatomy or extent of the lesion.
Lymphadenopathy - diag proced-surgery
- Biopsy should be considered if:
- Nodes are persistently enlarged, especially if accompanied by signs of systemic disease such as hepatosplenomegaly, weight loss, and exanthema.
- Nodes are fixed to underlying skin.
- Ulceration is present.
- Node is supraclavicular, nontender, or increasing in size or firmness.
- Fine-needle aspiration: Cost-effective, but sometimes nondiagnostic; may result in fistulous tract
- Open biopsy: Often diagnostic, but requires general anesthesia
Lymphadenopathy - differencial diagnosis
Must be carefully differentiated from lymphadenitis, defined as lymph node enlargement with signs of inflammation (erythema, tenderness, induration, warmth); often treated with antibiotics:
- Localized lymphadenopathy:
- Generally occurs as reactive adenopathy in response to local infection
- DDx for localized adenopathy varies depending on affected site.
- Cervical adenopathy: Includes cystic hygroma, branchial cleft cyst, and thyroglossal duct cyst
- Inguinal adenopathy: Includes inguinal hernia or other mass
- Generalized lymphadenopathy: May be seen in many systemic illnesses:
- Viral infections: Adenovirus, Rubella, Enteroviruses, Herpes simplex virus, Measles, Varicella, EBV, cytomegalovirus, HIV, hepatitis A or B
- Bacterial infections: Staphylococcus aureus, Bartonella henselae, GAS, Salmonella, Yesinia, Brucellosis, Tularemia, Mycobacterium tuberculosis, Mycoplasma pneumonia, Rickettsiae
- Parasitic infections: Chagas disease, Schistosomiasis
- Autoimmune disorders: SLE, juvenile rheumatoid arthritis, serum sickness
- Malignancy: Lymphoma (Hodgkin and non-Hodgkin), histiocytosis, neuroblastoma, leukemia
- Medications: Phenytoin, isoniazid, pyrimethamine, antileprosy drugs, antithyroid drugs, aspirin, barbiturates, penicillin, tetracycline, iodides, sulfonamides, allopurinol, phenylbutazone
- Lymphoproliferative disorders: Wiskott-Aldrich syndrome, ataxia-telangiectasia syndrome, combined immunodeficiency syndrome, x-linked lymphoproliferative syndrome
- Miscellaneous: Kawasaki disease, Castleman disease, Rosai-Dorfman disease (sinus histiocytosis with massive lymphadenopathy), Kikuchi-Fujimoto disease (histiocytic necrotizing lymphadenitis), Churg-Strauss syndrome, infection-associated hemophagocytic syndrome, Gianotti-Crosti syndrome (papular acrodermatitis), sarcoidosis, lipid storage diseases (Niemann-Pick, Gaucher, Wolman, Faber diseases), hyperthyroidism
Lymphadenopathy - TREATMENT
Lymphadenopathy - general measures
- Treat underlying disease.
- Close observation unless history and physical suggest malignancy or lymphadenitis
Lymphadenopathy - medication
Acute lymphadenitis should be treated with antibiotics directed against streptococcus and staphylococcus:
- Cephalexin 50 mg/kg/d in 4 divided doses or cefadroxil 30 mg/kg/d in 2 divided doses or Dicloxicillin 50–100 mg/kg/d in 4 divided doses. Max 4 g/d.
- Consider using Clindamycin 20–30 mg/kg/d in 4 divided doses in areas with a high prevalence of methacillin-resistant Staph aureus (MRSA)
- Penicillin-allergic patients: Erythromycin 50 mg/kg/d in 4 divided doses
Lymphadenopathy - first line
Empiric treatment with antibiotics: 1st- or 2nd- generation cephalosporin to cover group A streptococcus and S. aureus if meticulous history and physical exam are not revealing.
Lymphadenopathy - second line
Consider broader antibiotic coverage for B. henselae and atypical mycobacterium. Azithromycin 10 mg/kg dose on day 1, followed by 5 mg/kg divided once for 4 days
Lymphadenopathy - surgery
Excision for special, prolonged cases
Lymphadenopathy - FOLLOW UP
Lymphadenopathy - disposition
Lymphadenopathy - issues for referral
Refer to “Surgery” or “Otolaryngology” if biopsy or excision required.
Lymphadenopathy - prognosis
- Depends on underlying diagnosis
- Excellent for reactive lymphadenopathy
Lymphadenopathy - complications
- Lymphadenitis
- Local infection (e.g., cellulitis)
- Lymph node abscess
- Sepsis via hematogenous spread of inadequately contained infection
- Fistula (e.g., with atypical mycobacteria)
- Fibrosis secondary to purulence or lymphadenitis
- Stridor secondary to enlarged cervical lymph nodes
- Wheezing secondary to enlarged parabronchial mediastinal lymph nodes
Lymphadenopathy - patient monitoring
- Localized lymphadenopathy: Observe for several weeks or treat with antibiotics if indicated.
- Serial observation if nodes are persistently enlarged.
Lymphadenopathy - bibliography
- Albright JT, Pransky SM. Nontuberculous mycobacterial infections of the head and neck. Pediatr Clin North Am. 2003;50:503–514.
- Bamji M, Stone RK, Kaul A, et al. Palpable lymph nodes in healthy newborns and infants. Pediatrics. 1986;78:573–575.
Chesney PJ. Lymphatic system and generalized lymphadenopathy. In: Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. 2nd ed. New York: Churchill Livingstone; 2003:122–129.
- Margileth AM. Sorting out the causes of lymphadenopathy. Contemp Pediatr. 1995;12:23–40.
McClain KL, Fletcher RH. Evaluation of peripheral lymphadenopathy in children. In: Rose BD, ed. UpToDate. Wellesley, MA: UpToDate; 2003.
- Nield LS, Kamat D. Lymphadenopathy in children: When and how to evaluate. Clin Pediatr. 2004;43:25-33.
- Twist CJ, Link MP. Assessment of lymphadenopathy in children. Pediatr Clin North Am. 2002;49:1009–1025.
Lymphadenopathy - CODES
Lymphadenopathy - icd9
- 289.3 Inflamed lymph node or gland
- 785.6 Enlargement of lymph nodes
Lymphadenopathy - FAQ
- Q: When should there be concern about malignancy in a child with lymphadenopathy?
- A: Malignancy should be considered in any child who has lymphadenopathy that does not improve in spite of antibiotic therapy, that has a location of concern (e.g., supraclavicular) or physical exam features of concern (hard, large size [>2 cm]) that persistently enlarges, or if the child shows signs of systemic disease.
- Q: How much of a workup does a well child with localized lymphadenopathy need?
- A: As long as the lymph nodes are soft, mobile, and nontender, the lymphadenopathy is likely to be self-limited. If the cause is unclear, then children should be observed for a couple of weeks. Further workup is needed if the nodes persist or enlarge or if there are signs of systemic disease (e.g., hepatomegaly or weight loss).
- Q: When should a child with lymphadenopathy be referred to a specialist?
- A: Most cases of lymphadenopathy in children are self-limited and can be observed for a few weeks and/or treated with antibiotics, if appropriate. Referral to a surgeon should be considered in any child with persistently enlarged lymphadenopathy (>4 weeks) or immediately if there are signs of malignancy.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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