Lymphadenopathy, Localized
Lymphadenopathy, Localized: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Laeth S. Nasir
Approach
In clinical practice, the enlargement of a single lymph node or multiple contiguous lymph nodes is observed most commonly as a reaction to a well-defined process (e.g., impetigo or cellulitis) and requires no attention beyond treatment of the primary condition. However, lymphadenopathy as a primary complaint is often seen, and it requires further evaluation. Knowledge of the lymphatic drainage patterns of various regions of the body and the pathologic conditions most likely to affect these areas is critical in evaluating localized lymphadenopathy. The context in which lymphadenopathy is seen is very important. The age of the patient, the past medical history, and the presence of associated symptoms are all factors that need to be taken to account when planning a diagnostic assessment (1).
The lymphatic tissue of children is prominent when compared with that of adults. In fact, the absence of palpable lymph nodes in a child is sometimes the first clinical manifestation of an underlying immune deficiency. Viral or minor bacterial infections can lead to reactive lymphadenopathy, which is sometimes dramatic. The likelihood that lymphadenopathy is secondary to a benign process falls with increasing age. Patients aged less than 30 years are found to have a benign process causing their lymphadenopathy 80% of the time. However, 60% of individuals aged more than 50 years without a clear cause for localized lymphadenopathy will be found to have a malignancy on further evaluation (2).
History
A comprehensive history is critical in evaluating lymphadenopathy. It is important to elicit as accurately as possible the time course of the process. Progressive enlargement of a lymph node over several weeks or months suggests an underlying malignancy or granulomatous inflammation (e.g., tuberculosis or sarcoidosis). However, reactive lymphadenopathy can also persist for months. The presence of localizing or systemic signs (e.g., weight loss, night sweats, rash, or fever) suggests a particular pathologic process. Epidemiologic clues such as exposure to cats may suggest cat scratch disease. A history of contact with a new sexual partner raises the possibility of a sexually transmitted disease. Manifestations of regional lymphadenopathy within the thorax or abdomen can present as cough, shortness of breath, abdominal pain, urinary frequency, or intestinal obstruction. Rarely, pain in an area of lymphadenopathy following alcohol ingestion is the presenting symptom of Hodgkin’s disease.
Physical examination
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.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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