lymphadenopathy
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Etiology
- systemic infection
- scarlet fever (Streptococcus pyogenes)
- cat scratch disease (Bartonella henselae & Bartonella quintana)
- secondary syphilis (Treponema pallidum)
- Herpes simplex I & II
- human immunodeficiency virus (HIV)
- toxoplasmosis
- brucellosis
- rubella
- rubeola (measles)
- histoplasmosis
- dengue fever
- leptospirosis
- leishmaniasis
- trypanosomiasis (Trypanosoma rhodesiense & gambiense)
- Chagas' disease (Trypanosoma cruzi)
- disseminated tuberculosis
- Castleman's disease
- head & neck infection
- reactive
- diphtheria (Corynebacterium diphtheriae)
- Streptococcus pyogenes
- Archanobacterium haemolyticus
- herpangina (Coxsackie A virus)
- oral Herpes (Herpes simplex I & II)
- necrobacillosis (Fusobacterium necrophorum)
- dental abscess (mixed anaerobes/aerobes)
- infectious mononucleosis (EBV)
- cytomegalovirus (CMV)
- toxoplasmosis
- scrofula (Mycobacterium tuberculosis)
- Kawasaki disease
- Kikuchi's disease
- cat-scratch fever
- axillary infection
- abdominal infection
- mesenteric lymphadenitis (Yersinia enterocolitica)
- mycobacteriosis (Mycobacterium avium)
- inguinal infection
- immunologic disease
- malignancies
- hematologic
- Hodgkin's lymphoma
- acute leukemias (T-cell, B-cell, myeloid & monocytoid)
- chronic leukemias (T-cell, B-cell, myeloid & monocytoid)
- lymphomas
- malignant histiocytosis
- metastatic tumors to lymph nodes
- hematologic
- endocrine diseases
- lipid storage diseases
- miscellaneous & idiopathic diseases
- giant follicular lymph node hyperplasia (Castleman's disease)
- sinus histiocytosis
- dermatopathic lymphadenitis
- sarcoidosis
- amyloidosis
- mucocutaneous lymph node syndrome (Kawasaki disease)
- lymphomatoid granulomatosis
- multifocal Langerhans cell (eosinophilic) granulomatosis
- familial Mediterranean fever
- Kikuchi's histiocytic necrotizing lymphadenitis
- differential by location of adenopathy*
- suboccipital
- scalp infections
- mononucleosis
- toxoplasmosis
- tick bites
- lymphoma
- anterior auricular
- posterior auricular
- cervical
- head or neck cancer
- head or neck infection
- infectious mononucleosis
- Epstein-Barr virus
- cytomegalovirus
- toxoplasmosis
- rubella
- tuberculosis
- lymphoma
- metastatic cancer
- submandibular/submental
- neoplasms of the larynx or oropharynx
- dental disease
- thyroid cancer
- supraclavicular
- lymphoma
- breast cancer
- lung cancer
- gastrointestinal (GI) cancer
- infection
- lungs
- retroperitoneal space
- axillary
- infection
- trauma
- insect bites of hand or arm
- cat-scratch fever
- breast cancer
- lymphoma
- melanoma
- brucellosis
- epitrochlear
- hand infection
- lymphoma
- sarcoidosis
- tularemia
- secondary syphilis
- rheumatoid arthritis
- mediastinal/hilar/thoracic
- retroperitoneal
- inguinal
- lymphoma
- pelvic cancer
- sexually transmitted disease
- foot & leg infection & trauma
- Pasteurella pestis
- generalized (> 2 sites)
- suboccipital
- uncommon causes
- iatrogenic
* < 1% of lymphadenopathy in primary care due to malignancy
* risk of malignancy increases with age & chronicity
* younger persons are more likely to have infectious cause
Pathology
- lymphocyte proliferation & hyperplasia of non lymphoid cells in response to antigen exposure
- size of the lymph node increases
- nodal architecture is preserved
- entrapment of malignant cells* within lymph nodes results in malignant cells taking residence in lymph nodes, proliferating & causing nodal enlargement with destruction of nodal architecture
Clinical manifestations
- size: a lymph node larger than 1 cm in diameter is considered enlarged.
- location: see differential diagnosis
- mobility
- freely mobile lymph nodes are generally benign
- lymph nodes fixed to underlying tissue are generally malignant
- consistency
- infection
- tender
- asymmetric
- matted
- may have inflamed, red overlying skin
- lymphoma:
- large
- symmetric
- firm
- mobile;
- non tender
- rubbery
- metastatic tumor
- fixed
- hard
- discrete
- non tender
- infection
- temporal course
- constant
- intermittent
- associated signs/symptoms:
- cough
- fever suggests infection vs malignancy
- weight loss
- night sweats
- pruritus
- fatigue
- arthralgia
- myalgia
- hepatomegaly
- splenomegaly
- abdominal masses
Laboratory
- malignancy suspected (fevers, night sweats, weight loss)
- excisional lymph node biopsy*
- histologic examination
- culture
- antigenic typing
- chromosomal analysis
- molecular studies
- excisional lymph node biopsy*
- infection suspected
- autoimmune disease or connective tissue disease suspected
- see more specific disease
* NEJM knowledge+ seems to endorse fine needle aspiration followed by a core biopsy (maybe not)[7]
Radiology
Differential diagnosis
Management
- infection
- empiric treatment with antibiotics for no more than 1-2 weeks
- observation for 15-30 days after appropriate treatment
- other specifically directed therapy
- 50% of lymph node biopsies are non diagnostic
- 25% of patients with non-diagnostic biopsies develop disease in 1 year
- observation (without laboratory testing or imaging) for
- otherwise asymptomatic patients with
- cervical or inguinal lymphadenopathy and
- small, mobile lymph nodes of short duration (< several months)[2]
- small, soft, freely mobile lymph nodes limited to adjacent sites[2]
- cervical or inguinal lymphadenopathy and
- otherwise asymptomatic patients with
More general terms
More specific terms
- cervical lymphadenopathy
- hilar lymphadenopathy
- inguinal lymphadenopathy
- lymphadenitis
- mediastinal lymphadenopathy
- sinus histiocytosis
- sinus histiocytosis with massive lymphadenopathy; Rosai-Dorfman disease
- tonsillar hypertrophy
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 603-604
- ↑ 2.0 2.1 2.2 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 10. American College of Physicians, Philadelphia 1998, 2012, 2015, 2022
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 324
- ↑ Pangalis GA, Vassilakopoulos TP, Boussiotis VA, Fessas P. Clinical approach to lymphadenopathy. Semin Oncol. 1993 Dec;20(6):570-82. PMID: https://www.ncbi.nlm.nih.gov/pubmed/8296196
- ↑ Sahai S. Lymphadenopathy. Pediatr Rev. 2013 May;34(5):216-27. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23637250
- ↑ Soldes OS, Younger JG, Hirschl RB. Predictors of malignancy in childhood peripheral lymphadenopathy. J Pediatr Surg. 1999 Oct;34(10):1447-52. PMID: https://www.ncbi.nlm.nih.gov/pubmed/10549745
- ↑ 7.0 7.1 NEJM Knowledge+ Complex Medical Care