Lymphadenopathy
Differential Overview
Generalized
❑ Infectious mononucleosis
❑ Drugs
❑ Connective tissue disease
❑ HIV infection
❑ Sarcoidosis
❑ Serum sickness
❑ Toxoplasmosis
❑ Secondary syphilis
Localized
❑ Regional infection
❑ Lymphadenitis
❑ Hodgkin lymphoma
❑ Cat-scratch disease
Diagnostic Approach
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.
Clinical Findings
Infectious mononucleosis The typical presentation is an adolescent or young adult with prominent fatigue, fever, and sore throat with exudative tonsillitis. Posterior cervical adenopathy and splenomegaly (50%) may be found. Petechiae can often be seen at the junction of the soft and hard palate.
Drugs Lymphadenopathy can be caused by phenytoin, allopurinol, hydralazine, carbamazepine, antithyroid medications, and isoniazid.
Connective tissue disease In rheumatoid arthritis, adenopathy occurs in areas draining the involved joints. Felty syndrome (with neutropenia) is marked by splenomegaly and generalized lymphadenopathy. Generalized lymphadenopathy is seen in 50% of patients, especially at the onset or with exacerbations. Mixed connective tissue disease and Sjogren are also associated with lymphadenopathy.
HIV infection Lymphadenopathy occurs in 75% of patients with acute HIV syndrome, usually in the second week. Consider acute HIV in a patient with fever, widespread diffuse maculopapular rash including the palms and mucocutaneous ulceration, and a recent high-risk exposure. Chronic undiagnosed HIV infection can be recognized by noting weight loss, thrush, fever, and HIV risk factors.
Sarcoidosis Parotid or lacrimal gland enlargement is common. Skin lesions are waxy and reddish-brown or deeply indurated. Scalp lesions with scarring alopecia may also occur.
Serum sickness Consider when fever, rash, and acute polyarthritis occur in a patient who is taking a new medication.
Toxoplasmosis Look for exposure to cats or turtles.
Secondary syphilis A generalized scaling rash including the palms and soles is characteristic. Painless silver-gray erosions on the oral or genital mucosa may also be found.
Regional infection Infection may be subtle, such as dermatophytes or scabies. Gardening scrapes may be infected with sporotrichosis.
Lymphadenitis A tender, warm, red, rapidly enlarging node reflects acute pyogenic infection of the node itself.
Hodgkin lymphoma A chain of large, rubbery, nontender nodes; a palpable spleen; and lymphoma B symptoms of night sweats and fever are helpful clues. Alcohol consumption may produce pain in the nodes.
Cat-scratch disease The primary lesion is similar to a furuncle, associated with unilateral regional lymphadenopathy. Lymphangitis is absent, but constitutional symptoms are present.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Lymph symptoms
Read excerpts from these other book chapters related to Lymph symptoms:
Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Lymph symptoms
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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Lymphadenopathy (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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