Lymphadenopathy

Lymphadenopathy: Excerpt from In a Page: Signs and Symptoms

Lymphadenopathy refers to enlargement of the lymph nodes. Localized lymphadenopathy involves one lymph region, whereas generalized lymphadenopathy involves more than one region. More than two thirds of cases of lymphadenopathy in primary care are due to nonspecific causes or upper respiratory illnesses. Underlying malignancy must be ruled out; however, less than 1% of cases are due to an underlying malignancy.

Differential Diagnosis

Generalized lymphadenopathy (e.g., cervical, supraclavicular, axillary, and inguinal lymphadenopathy; hepatomegaly; splenomegaly)

• Infection
  –Tuberculosis
  –Secondary syphilis
  –Mononucleosis
  –HIV/AIDS
  –Kawasaki's syndrome
  –Typhoid fever
• Hypersensitivity reactions
  –Serum sickness
  –Drugs (e.g., hydantoin, phenytoin, hydralazine, allopurinol, primidone)
• Lymphoma
• Leukemia
• Connective tissue disorders (e.g., SLE, rheumatoid arthritis)
• Sarcoidosis
• Metastatic cancer [especially with left supraclavicular lymphadenopathy (Virchow's node) associated with abdominal malignancies, including stomach, pancreas, gallbladder, testis/ovary, kidney, and prostate cancers]
• Endocrine disorders (e.g., hyperthyroidism, hypoadrenalism)
• Amyloidosis
• Castleman's syndrome (angiofollicular lymph node hyperplasia)
• Kikuchi's disease
  Localized lymphadenopathy
• Reactive hyperplasia, local inflammation (e.g., dermatitis, vaccination, trauma)
• Infection
  –Viral: Mononucleosis, CMV, HIV, rubella, mumps
  –Bacterial: Streptococcus, tuberculosis, salmonella, cat-scratch disease (due to Bartonella henselae); gonorrhea, Chlamydia, and other sexually transmitted diseases (inguinal)
  –Parasitic: Malaria, toxoplasmosis
  –Fungal: Histoplasmosis, coccidioidomycosis
  • Lymphoma or metastatic disease (e.g. head and neck squamous cell cancer leads to cervical lymphadenopathy)

  Workup and Diagnosis

  • History and physical examination
    –Note extent of lymphadenopathy (localized or generalized), size of nodes, texture, presence or absence of nodal tenderness (tenderness suggests infection), signs of inflammation over the node, skin lesions, petechiae, splenomegaly, and hepatomegaly
    –Thorough ENT examination in adult patients with cervical adenopathy and/or a history of tobacco use
    –Supraclavicular and epitrochlear lymphadenopathy carry a high risk of malignancy or other abnormality and are rarely normal or reactive
    –Lymph nodes greater than 1 cm, and particularly greater than 2 cm, are likely to be pathologic
  • Initial labs may include CBC, peripheral smear, ESR, CRP, uric acid, PPD, blood cultures, viral titers for specific organisms (e.g., HIV, CMV, toxoplasmosis, rubella), and serologies for brucellosis and typhoid
    –Atypical lymphocytes may indicate a viral illness
    –Immature leukocytes/blasts may indicate leukemia
    –Leukocytosis often indicates infection
  • Chest X-ray and/or abdominal ultrasound may be used to evaluate for lymphadenopathy
  • Biopsy is the gold standard for diagnosis
    –Strongly consider biopsy if node is >2.0 cm, associated with abnormal chest X-ray, and/or age >40 years
  • Bone marrow aspiration may be necessary in some cases to rule out an underlying malignancy

  Treatment

  • Viral infections require supportive therapy in most cases
  • Bacterial, parasitic, and fungal infections are usually treated with appropriate antibiotics, antiparasitics or antifungals, respectively
  • Offending medication should be removed when possible
  • Malignancies must be identified, staged, and treated as appropriate with chemotherapy, radiation, and/or resection as per the established oncology protocol

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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