Diagnostic Tests for Lymphatic Filariasis
Lymphatic Filariasis: Diagnostic Tests
The list of diagnostic tests
mentioned in various sources as
used in the diagnosis of Lymphatic Filariasis
includes:
Lymphatic Filariasis Tests: Book Excerpts
Lymphatic Filariasis Diagnosis: Book Excerpts
Diagnostic Tests for Lymphatic Filariasis: Online Medical Books
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LYMPHADENOPATHY:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine diagnostic tests include a CBC, sedimentation rate, nose and throat culture, and culture of material from any area supplied by the enlarged lymph nodes. Blood cultures are indicated in generalized lymphadenopathy. In addition, a chemistry panel should be done, as well as a heterophile antibody titer, brucellin antibody titer, febrile agglutinins, and VDRL test. A chest x-ray and flat plate of the abdomen may be helpful in diagnosing generalized lymphadenopathy. HIV testing is done in patients with a history of high-risk sexual behavior.
X-ray of the long bones may identify metastatic carcinoma, and x-ray of the hands may identify sarcoidosis. A bone marrow examination may identify leukemia or lymphoma. If an infectious process has been ruled out, biopsy of the local node may turn up metastatic carcinoma, Hodgkin's disease, and sarcoidosis. A tuberculin skin test should be done; a Brucellergen skin test and Kveim test may also need to be done. ANA and
rheumatoid arthritis factor
testing may need to be done to rule out a collagen disease. A lymphangiogram may turn up a lymphosarcoma or multiple metastatic lymph nodes. Liver biopsy is also occasionally necessary. Imaging studies of the abdomen and pelvis and the mediastinum are occasionally necessary. Mediastinoscopy may facilitate getting a tissue diagnosis. Before ordering these, a consultation with a hematologist or infectious disease specialist would be prudent.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Lymphadenopathy:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when he first noticed the swelling and whether it’s located on one side of his body or both. Are the swollen areas sore, hard, or red? Ask the patient if he has recently had an infection or other health problem. Also ask if a biopsy has ever been done on any node because this may indicate a previously diagnosed cancer. Find out if the patient has a family history of cancer.
Palpate the entire lymph node system to determine the extent of lymphade-nopathy and to detect other areas of local enlargement. Use the pads of your index and middle fingers to move the skin over underlying tissues at the nodal area. If you detect enlarged nodes, note their size in centimeters and whether they’re fixed or mobile, tender or nontender, and erythematous or not. Note their texture: Is the node discrete, or does the area feel matted? If you detect tender, erythematous lymph nodes, check the area drained by that part of the lymph system for signs of infection, such as erythema and swelling. Also, palpate for and percuss the spleen.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Lymphadenopathy:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when he first noticed the swelling, and whether it’s located on one side of his body or both. Are the swollen areas sore, hard, or red? Ask the patient if he has recently had an infection or other health problem. Also ask if a biopsy has ever been done on any node because this may indicate a previously diagnosed cancer. Find out if the patient has a family history of cancer.
Palpate the entire lymph node system to determine the extent of lymphadenopathy and to detect any other areas of local enlargement. Use the pads of your index and middle fingers to move the skin over underlying tissues at the nodal area. If you detect enlarged nodes, note their size in centimeters and whether they’re fixed or mobile, tender or nontender, and erythematous or not. Note their texture: Is the node discrete, or does the area feel matted? If you detect tender, erythematous lymph nodes, check the area drained by that part of the lymph system for signs of infection, such as erythema and swelling. Also, palpate for and percuss the spleen.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Lymphadenopathy, Generalized:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. General. A comprehensive physical examination should be performed on all patients with generalized lymphadenopathy. Focus on those findings consistent with the most frequent causes of generalized lymphadenopathy. Note the patient’s temperature and weight, because fever and weight loss are frequent findings. Examine the skin, mucous membranes, abdominal organs, and joints; specifically, the presence of rash, mucocutaneous ulceration, organomegaly, and arthritis can be a guide to possible causes of the adenopathy. The presence of splenomegaly in a patient with adenopathy implies a systemic illness (e.g., infectious mononucleosis, lymphoma, leukemia, lupus, sarcoidosis, toxoplasmosis, or cat scratch disease) (Chapter 15.4). Additionally, search for other abnormal lymph nodes. Studies have shown that clinicians identified only 17% of those cases of generalized lymphadenopathy when it was present (1).
B. Nodal examination. The abnormal lymph node groups should be specifically examined.
1. Size. Lymph nodes enlarged up to 1 cm in diameter can be considered normal in size. These have a low malignancy risk and can usually be observed. Lymph nodes greater than 1.5 cm × 1.5 cm in area have been shown to have a 38% risk of cancer involvement and merit further workup (2).
2. Location. Anterior cervical, submandibular, and inguinal nodes are normally palpable. The presence of supraclavicular adenopathy is always abnormal and carries a 90% cancer risk in those aged more than 40 years. Postocciptal nodes are associated with infectious mononucleosis, scalp lesions, toxoplasmosis, and non-Hodgkin’s lymphoma. Axillary nodes are associated with upper extremity infections, breast cancer, cat scratch disease, and lymphomas. Epitrochlear nodes are associated with pyogenic infections, sarcoidosis, tularemia, and syphilis. Inguinal nodes are associated with lower extremity infections and sexually transmitted diseases.
3. Pain. The presence or absence of pain is not a reliable indicator of the cause of adenopathy. Capsular swelling from acute infections can cause pain as can necrotic hemorrhage from a malignant lymph node.
4. Consistency. Rock hard nodes are consistent with metastatic disease (2). Firm rubbery nodes are found with lymphomas. Soft nodes tend to occur with infectious causes; however, this should not be considered diagnostic.
Testing
A. Primary laboratory test. Initial laboratory testing should include a complete blood count (CBC) and a slide test for infectious mononucleosis (IM) (1). Atypical lymphocytes are suggestive of IM, cytomegalovirus, or toxoplasmosis. Neutropenia is found with viral illness, lupus, brucellosis, and bone marrow replacement. Severe anemia can be seen with malignancy and autoimmune processes. If the initial mononucleosis spot is negative, the test should be repeated at intervals of 1, 2, and 3 weeks, if atypical lymphocytes are present in the CBC.
B. Secondary testing. If the initial laboratory results are nondiagnostic, order a purified protein derivative (PPD), antinuclear antibody, hepatitis B surface antigen, HIV, rapid plasma reagin, cytomegalovirus serology, and chest X-ray (CXR) study. Although the CXR is seldom positive, it can be helpful in finding tuberculosis (TB), histoplasmosis, lymphoma, or sarcoidosis. Although a PPD will not be diagnostic of TB, it can be helpful in differentiating sarcoid from TB on a node biopsy (2).
C. Lymph node biopsy. If the aforementioned laboratory testing is nondiagnostic, then lymph node biopsy may be indicated. The largest and most pathologic node should be removed. Axillary and inguinal nodes should be avoided as they often reveal only reactive hyperplasia. Biopsy should be avoided in cases of suspected IM and drug reaction because the histologic picture is easily confused with malignant lymphoma (2). Experienced hematologists or hematopathologists should handle all specimens. The value of fine needle aspiration is controversial, with reasonable arguments both for and against (4).
Diagnostic assessment
Generalized lymphadenopathy merits evaluation beyond mere observation, as a specific systemic illness will be the likely cause. The history and examination should focus on infectious, autoimmune, granulomatous, and malignant causes. If a specific entity is suspected based on the history and physical examination, then that entity should be specifically evaluated. In the event the cause is unclear, first order a CBC and mononucleosis spot. If these are negative, then serologic testing and a CXR are warranted. Consider lymph node biopsy in those cases where the node is rock hard or larger than 1.5 cm × 1.5 cm in size (1). Biopsy should be avoided in those cases where viral causes are clinically suggested.
References
1. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician 1998;58:1313–1320.
2. Pangalis GA, Vassilalopoulos TP, Boussiotis VA, Fessas P. Clinical approach to lymphadenopathy. Semin Oncol 1993;20:570–582.
3. Williamson HA. Lymphadenopathy in a family practice. J Fam Pract 1985;20:
449–452.
4. Henry P, Longo D. Enlargement of lymph nodes and spleen. Harrison’s on line 1999;61. www.harrisonsonline.com/
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Lymphadenopathy, Localized:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
On physical examination, the first question that needs to be answered is whether the structure being palpated is truly a lymph node. Parotid enlargement, thyroid masses, sternocleidomastoid tumors, dermoid cysts, hemangiomas, or other tumors occasionally mimic lymphadenopathy. Thoroughly examine the anatomic region or regions drained by the affected nodes. Carefully note the characteristics of the lymph nodes and surrounding tissues. Tender lymph nodes that are mobile often represent lymphadenitis or acute inflammation. Matted, hard lymph nodes that are fixed to surrounding tissue imply an underlying metastatic carcinoma. Rubbery, nontender nodes may be seen in lymphoma.
In otherwise healthy children, lymph nodes up to 2.5 cm in diameter, particularly in the inguinal, suboccipital, and cervical regions, may be seen (3). In adults, lymph nodes larger than 1 cm in diameter should arouse suspicion, and nodes larger than 3 cm are highly suggestive of a malignant process (2). In both children and adults, supraclavicular lymph nodes larger than 1 or 2 cm in diameter should be investigated aggressively.
Testing
Testing is often done to uncover pathology involving the region of the body drained by the affected lymph nodes. For example, cultures for venereal disease may be obtained in inguinal adenopathy, or sinus films in cervical adenopathy if clinically indicated. Consider radiographic techniques such as ultrasound or computerized tomographic scanning of the thorax or abdomen if lymphadenopathy is suspected in these locations. In some cases, watchful waiting may be diagnostically useful. In cases where a serious condition is suspected or cannot be ruled out, the test of choice is an excisional biopsy of the node or nodes involved. The lymph node chosen for biopsy is important. In general, it is preferable to obtain a biopsy from large nodes that have recently enlarged. Mediastinal nodes can be biopsied via bronchoscopy, mediastinoscopy, or thoracotomy. Intraabdominal adenopathy can be evaluated by fluoroscopically guided needle biopsy or exploratory laparotomy. The biopsy material obtained by any of these methods can be submitted for both pathologic study and bacteriologic testing. In lymph nodes that are fluctuant, consider needle aspiration or biopsy. Carefully follow up patients who are diagnosed as having nonspecific changes or reactive hyperplasia, because a proportion of these will ultimately be diagnosed as having a lymphoma. Patients who are human immunodeficiency virus-positive or have a history of a previous malignancy have a higher likelihood of serious pathology, and the threshold for aggressive investigation should be low (4).
Diagnostic assessment
The cause of localized lymphadenopathy can be conveniently classified based on the location of the enlarged nodes. Enlarged occipital nodes, which are common in children, most often are caused by scalp infections such as tinea capitis. Seborrheic dermatitis, rubella, and roseola are other common causes. In both children and adults, enlarged preauricular nodes caused by conjunctival infections or cat scratch disease may be seen. Cervical adenopathy can be caused by infections of the sinuses, pharynx, or soft tissues of the face. In children, Kawasaki’s disease can result in cervical adenopathy, which may be unilateral. Acute leukemias, rhabdomyosarcoma, or neuroblastoma can also present in this way (5). Hodgkin’s disease or non-Hodgkin’s lymphoma can present with cervical adenopathy. Squamous cell carcinoma from the nasopharynx or laryngeal area is a common occurrence in older individuals.
Supraclavicular lymphadenopathy is a particularly worrisome finding in both children and adults, as this pattern of nodal enlargement is frequently associated with granulomatous conditions and malignancies. Classically, the right supraclavicular area is described as receiving drainage from the intrathoracic organs, whereas the left supraclavicular lymph nodes drain the abdomen. The supraclavicular lymph nodes also receive lymphatic drainage from the breasts. Enlarged axillary nodes may be seen secondary to inflammatory or malignant disease of the upper extremity, or breast, as a reaction to immunizations in the ipsilateral arm, and occasionally in autoimmune disorders such as juvenile rheumatoid arthritis. Isolated epitrochlear or popliteal lymphadenopathy is most commonly caused by local infection; however, local melanoma should be carefully excluded. Enlarged inguinal nodes are most commonly caused by local infection. In children, this includes diaper dermatitis and infections of the lower extremities. In adults, lymphogranuloma venereum or syphilis commonly presents with unilateral inguinal adenopathy. Common causes of mediastinal adenopathy include bronchogenic carcinoma, lymphoma, tuberculosis or sarcoidosis, histoplasmosis or coccidioidomycosis, and Hodgkin’s disease. Intraabdominal adenopathy is often caused by Hodgkin’s and non-Hodgkin’s lymphoma or tuberculosis.
References
1. Slap GB, Connor JL, Wigton RS, Schwartz JS. Validation of a model to identify young patients for lymph node biopsy. JAMA 1986;225:2768–2773.
2. Simon HB. Evaluation of lymphadenopathy. In: Goroll AH, May LA, Mulley AG. Primary care medicine: office evaluation and management of the adult patient, 3rd ed. Philadelphia: JB Lippincott, 1995:54–58.
3. Bedros AA, Mann JP. Lymphadenopathy in children. Adv Pediatr 1981;28:341–376.
4. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician 1998;58:1313–1320.
5. Marcy SM. Cervical adenitis. Pediatr Infect Dis J 1985;4:S23–S26.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Lymphadenopathy:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Palpable adenopathy is present in half of healthy young adults. Red flags for malignancy include a node larger than 2 cm in size and enlarging, age older than 40 years, weight loss greater than 10%, and a supraclavicular node. Constitutional symptoms such as fever, night sweats and weight loss should prompt further evaluation. On occasion, reactive lymphadenopathy may persist for months, but observation for enlargement over time is a useful tool to select which patients need biopsy. Nodes with an irregular shape and firm rubbery consistency suggest malignancy. Matted nodes or those fixed to the deep fascia also suggest malignancy.
Coexistence of splenomegaly implies a systemic illness such as lymphoma/leukemia, infectious mononucleosis, systemic lupus, sarcoidosis, or toxoplasmosis.
Structures that may be mistaken for cervical lymph nodes include the parotid gland, thyroglossal and branchial cysts, an abscess, a lipoma, thyroid nodules, submaxillary infections, or dental infections.
Tenderness is usually associated with an infectious etiology. Fluctuation or suppuration occuring over a few days is usually due to staphylococcal or streptococcal infection. Progression over weeks to months occurs with tuberculosis, atypical mycobacteria, Bartonella (cat-scratch disease), sporotrichosis or rare cases of anthrax, plague, tularemia, chancroid, or lymphogranuloma venereum.
The location of adenopathy narrows the differential:
Anterior cervical Unilateral: pharyngitis, thyroid cancer, nasopharyngeal cancer, or buccal infection. Bilateral: pharyngitis, mononucleosis, sarcoidosis, or toxoplasmosis.
Preauricular They are common in oculoglandular fevers such as adenoviral conjunctivitis, rubella, tularemia, and leptospirosis. These are also commonly found in infection in the cheek, eyelid, ear, or temporal scalp. If a source is not evident, look for a retinal melanoma.
Posterior auricular Consider infectious mononucleosis, rubella, otitis media, lymphoma, or head and neck malignancy.
Right supraclavicular Consider an intrathoracic (lungs, mediastinum, or esophagus) malignancy.
Left supraclavicular A sentinel or Virchow node, draining the thoracic duct, suggests intra-abdominal malignancy (stomach, gallbladder, pancreas, kidneys, testicles, ovaries, or prostate).
Axillary Drainage is from the arm, chest wall, and breast, so consider breast malignancy, upper extremity infection such as cat-scratch disease, or Hodgkin lymphoma.
Epitrochlear Consider secondary syphilis (bilateral), hand infection (unilateral), sarcoidosis and rheumatoid arthritis (helps differentiate from osteoarthritis).
Inguinal A lower extremity infection or sexually transmitted disease (primary syphilis, genital herpes, chancroid, lymphogranuloma venereum) are the usual causes. Regional metastases from the skin (e.g. melanoma) or genital organs also occur. A femoral hernia can be confused with adenopathy.
Occipital Consider scalp infection (especially pediculosis capitis), secondary syphilis, Hodgkin lymphoma, and tuberculosis.
Periumbilical Consider abdominal malignancy.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Lymphadenopathy:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Palpate the entire lymph node system to determine the extent of lymphadenopathy and to detect other areas of local enlargement. Use the pads of your index and middle fingers to move the skin over underlying tissues at the nodal area. If you detect enlarged nodes, note their size in centimeters and whether they’re fixed or mobile, tender or nontender, and erythematous. Note their texture: Is the node discrete, or does the area feel matted? If you detect tender, erythematous lymph nodes, check the area drained by that part of the lymph system for signs of infection, such as erythema and swelling. Also, palpate for and percuss the spleen.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Lymphadenopathy:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
First stepis to determine whether lymph nodes are enlarged.If they are enlarged, next step isto determine whether adenopathy is localized or generalized.Most commoncauses of localized adenopathy are reactive hyperplasia and infection.Most common causes of generalized adenopathyare reactive hyperplasia, infection, and neoplasia.Occasionally, some disorders that causegeneralized adenopathy may present with localized adenopathy. Diagnosticapproach to cervical adenitis is discussed in Chap. 42, Neck Masses. If cause of generalized adenopathyis uncertain after history and physical exam, CBC and differential,monospot test, and chest radiography should be performed.Infectiousmononucleosis is still possible with negative monospot test, andEBV serologies can be performed.Cytomegalovirus infection also cancause infectious mononucleosis-like syndrome, and viral isolationfrom urine is diagnostic.HIV serology should be considered.Bone marrow aspirate or biopsy shouldbe considered if there is pancytopenia or malignant cells are seenon blood smear.If CBC is normal or mild anemia ispresent, degree of illness must be assessed. With mild illness,child may be followed for 1–2 wks and reassessed. If illnessis more severe or neoplasia is suspected, further investigationis indicated.Lymph node biopsy or bone marrow aspiratemay be diagnostic. In many cases, reactive hyperplasiaand not infection or neoplasia is cause of lymph node enlargement.These children should be observed to see whether regression occurs.If node doesnot change in size or character in 6–8 wks, then biopsyshould be considered.If node rapidly enlarges, biopsy isrecommended even if all other test results are normal. If biopsyis nondiagnostic, it is still important to follow patients closely.In review by Lake and Oski (1978),of 41 children initially found to have nondiagnostic reactive hyperplasia,17% ultimately proved to have specific pathologic diagnosis.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Lymphadenopathy:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when he first noticed the swelling and whether it's located on one side of his body or both. Are the swollen areas sore, hard, or red? Ask the patient if he has recently had an infection or other health problem. Also ask if a biopsy has ever been done on any node because this may indicate a previously diagnosed cancer. Find out if the patient has a family history of cancer.
Palpate the entire lymph node system to determine the extent of lymphadenopathy and to detect other areas of local enlargement. Use the pads of your index and middle fingers to move the skin over underlying tissues at the nodal area. If you detect enlarged nodes, note their size in centimeters and whether they're fixed or mobile, tender or nontender, and erythematous or not. Note their texture: Is the node discrete, or does the area feel matted? If you detect tender, erythematous lymph nodes, check the area drained by that part of the lymph system for signs of infection, such as erythema and swelling. Also, palpate for and percuss the spleen.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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