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
- 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*
- avoid in patients with suspected head & neck cancer
- may compromise potential surgery by disrupting tissue planes in the neck[2]
- see head & neck cancer
- histologic examination
- culture
- antigenic typing
- chromosomal analysis
- molecular studies
- avoid in patients with suspected head & neck cancer
- 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]
Diagnostic procedures
- direct laryngoscopy initial testing for upper cervical lymph node
Radiology
Differential diagnosis
Management
- malignancy suspected (fevers, night sweats, weight loss)
- excisional lymph node biopsy (a 5 cm axillary mass is acceptable)[2]
- biopsy should be performed at the lymphadenopathy of greatest PET uptake, assuming it can be safely accessed[2]
- 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 2.3 2.4 2.5 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 10. American College of Physicians, Philadelphia 1998, 2012, 2015, 2022
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ 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://pubmed.ncbi.nlm.nih.gov/8296196
- ↑ Sahai S. Lymphadenopathy. Pediatr Rev. 2013 May;34(5):216-27. PMID: https://pubmed.ncbi.nlm.nih.gov/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://pubmed.ncbi.nlm.nih.gov/10549745
- ↑ 7.0 7.1 NEJM Knowledge+ Complex Medical Care