Lymphadenopathy
Lymphadenopathy: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Lymphadenopathy — enlargement of one or more lymph nodes — may result from increased production of lymphocytes or reticuloendothelial cells or from infiltration of cells that aren’t normally present. This sign may be generalized (involving three or more node groups) or localized. Generalized lymphadenopathy may be caused by an inflammatory process, such as bacterial or viral infection, connective tissue disease, an endocrine disorder, or neoplasm. Localized lymphadenopathy most commonly results from infection or trauma affecting a specific area. (See Areas of localized lymphadenopathy. Also see Causes of localized lymphadenopathy, page 386.)
Normally, lymph nodes are discrete, mobile, soft, nontender and, except in children, nonpalpable. (However, palpable nodes may be normal in adults.) Nodes that are more than ⅜" (1 cm) in diameter are cause for concern. They may be tender, and the skin overlying the lymph node may be erythematous, suggesting a draining lesion. Alternatively, they may be hard and fixed, tender or nontender, suggesting a malignant tumor.
History and physical examination
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.
Medical causes
Acquired immunodeficiency syndrome
Besides lymphadenopathy, findings include a history of fatigue, night sweats, afternoon fevers, diarrhea, weight loss, and a cough with several concurrent infections appearing soon afterward.
Anthrax (cutaneous)
Lymphadenopathy, malaise, a headache, and a fever may develop along with a lesion that progresses into a painless, necrotic-centered ulcer.
Brucellosis
Generalized lymphadenopathy usually affects cervical and axillary lymph nodes, making them tender
Brucellosis usually begins insidiously with easy fatigability, malaise, headache, backache, anorexia, weight loss, and arthralgia; it may also begin abruptly with chills, a fever that usually rises in the morning and subsides during the day, and diaphoresis.
Cytomegalovirus infection
Generalized lymphadenopathy occurs in the immunocompromised patient and is accompanied by a fever, malaise, a rash, and hepatosplenomegaly.
Hodgkin’s disease
The extent of lymphadenopathy reflects the stage of malignancy — from stage I involvement of a single lymph node region to stage IV generalized lymphadenopathy
Common early signs and symptoms include pruritus and, in older patients, fatigue, weakness, night sweats, malaise, weight loss, and an unexplained fever (usually to 101° F [38.3° C]). Also, if mediastinal lymph nodes enlarge, tracheal and esophageal pressure produces dyspnea and dysphagia.
Leptospirosis
Lymphadenopathy occurs infrequently in leptospirosis, a rare disease
More common findings include a sudden onset of a fever and chills, malaise, myalgia, a headache, nausea and vomiting, and abdominal pain.
Leukemia (acute lymphocytic)
Generalized lymphadenopathy is accompanied by fatigue, malaise, pallor, and a low-grade fever
The patient also experiences prolonged bleeding time, swollen gums, weight loss, bone or joint pain, and hepatosplenomegaly.
Leukemia (chronic lymphocytic)
Generalized lymphadenopathy appears early, along with fatigue, malaise, and a fever
As the disease progresses, hepatosplenomegaly, severe fatigue, and weight loss occur. Other late findings include bone tenderness, edema, pallor, dyspnea, tachycardia, palpitations, bleeding, anemia, and macular or nodular lesions.
Lyme disease
Spread by the bite of certain ticks, Lyme disease begins with a skin lesion called erythema chronicum migrans
As the disease progresses, the patient may suffer from lymphadenopathy, constant malaise and fatigue, and an intermittent headache, a fever, chills, and aches. He may go on to develop arthralgia and, eventually, neurologic and cardiac abnormalities.
Mononucleosis (infectious)
Characteristic, painful lymphadenopathy involves cervical, axillary, and inguinal nodes. Posterior cervical adenopathy is also common. Typically, prodromal symptoms — such as a headache, malaise, and fatigue — occur 3 to 5 days before the appearance of the classic triad of lymphadenopathy, sore throat, and temperature fluctuations with an evening peak of about 102° F (38.9°C). Hepatosplenomegaly may develop, along with findings of stomatitis, exudative tonsillitis, or pharyngitis.
Mycosis fungoides
Lymphadenopathy occurs in stage III of mycosis fungoides, a rare, chronic malignant lymphoma
It’s accompanied by ulcerated brownish red tumors that are painful and itchy.
Non-Hodgkin’s lymphoma
Painless enlargement of one or more peripheral lymph nodes is the most common sign of non-Hodgkin’s lymphoma, with generalized lymphadenopathy characterizing stage IV
Dyspnea, a cough, and hepatosplenomegaly occur, along with systemic complaints of a fever of up to 101° F (38.37 C), night sweats, fatigue, malaise, and weight loss.
Plague (Yersinia pestis)
and symptoms of the bubonic form of plague, a bacterial infection, include lymphadenopathy, a fever, and chills.
Rheumatoid arthritis
Lymphadenopathy is an early, nonspecific finding associated with fatigue, malaise, a continuous low-grade fever, weight loss, and vague arthralgia and myalgia
Later, the patient develops joint tenderness, swelling, and warmth; joint stiffness after inactivity (especially in the morning); and subcutaneous nodules on the elbows. Eventually joint deformity, muscle weakness, and atrophy may occur.
Sarcoidosis
Generalized, bilateral hilar and right paratracheal forms of lymphadenopathy (seen on chest X-ray) with splenomegaly are common
Initial findings are arthralgia, fatigue, malaise, weight loss, and pulmonary symptoms. Other findings vary with the site and extent of fibrosis. Typical cardiopulmonary findings include breathlessness, a cough, substernal chest pain, and arrhythmias. About 90% of patients have an abnormal chest X-ray at sometime during their illness. Musculoskeletal and cutaneous features may include muscle weakness and pain, phalangeal and nasal mucosal lesions, and subcutaneous skin nodules. Common ophthalmic findings include eye pain, photophobia, and nonreactive pupils. Central nervous system involvement may produce cranial or peripheral nerve palsies and seizures.
Sjögren’s syndrome
Lymphadenopathy of the parotid and submaxillary nodes may occur in Sjögren’s syndrome, a rare disorder
Assessment reveals cardinal signs of dry mouth, eyes, and mucous membranes, which may be accompanied by photosensitivity, poor vision, eye fatigue, nasal crusting, and epistaxis.
Syphilis (secondary)
Generalized lymphadenopathy occurs in the second stage and may be accompanied by a macular, papular, pustular, or nodular rash on the arms, trunk, palms, soles, face, and scalp
A palmar rash is a significant diagnostic sign. A headache, malaise, anorexia, weight loss, nausea, vomiting, a sore throat, and a low-grade fever may occur.
Systemic lupus erythematosus
Generalized lymphadenopathy typically accompanies the hallmark butterfly rash, photosensitivity, Raynaud’s phenomenon, and joint pain and stiffness
Pleuritic chest pain and a cough may appear with systemic findings, such as a fever, anorexia, and weight loss.
Tuberculous lymphadenitis
Lymphadenopathy may be generalized or restricted to superficial lymph nodes
Affected lymph nodes may become fluctuant and drain to surrounding tissue. They may be accompanied by a fever, chills, weakness, and fatigue.
Waldenström’s macroglobulinemia
Lymphadenopathy may appear along with hepatosplenomegaly
Associated findings include retinal hemorrhage, pallor, and signs of heart failure, such as jugular vein distention and crackles. The patient shows a decreased level of consciousness, abnormal reflexes, and signs of peripheral neuritis. Weakness, fatigue, weight loss, epistaxis, and GI bleeding may also occur. Circulatory impairment occurs because of increased blood viscosity.
Other causes
Drugs
Phenytoin may cause generalized lymphadenopathy.
Immunizations
Typhoid vaccination may cause generalized lymphadenopathy.
Special considerations
If the patient has a fever above 101° F (38.3°C), don’t automatically assume that the temperature should be lowered
A patient with a bacterial or viral infection must tolerate the fever, which may assist recovery. Provide an antipyretic if the patient is uncomfortable. Tepid sponge baths or a hypothermia blanket may also be used.
Expect to obtain blood for routine blood work, platelet and white blood cell counts, liver and renal function studies, erythrocyte sedimentation rate, and blood cultures. Prepare the patient for other scheduled diagnostic tests, such as chest X-ray, liver and spleen scan, lymph node biopsy, or lymphography, to visualize the lymphatic system. If tests reveal infection, check your facility’s policy regarding infection control and isolation precautions.
Pediatric pointers
Infection is the most common cause of lymphadenopathy in children. The condition is commonly associated with otitis media and pharyngitis.
Provide an antipyretic if the child has a history of febrile seizures.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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