Lymphadenopathy resident survival guide
|Lymphadenopathy resident survival guide microchapters|
Lymphadenopathy (LAD) is used to describe abnormal size, consistency, and the number of lymph nodes. Under normal conditions, lymph nodes may not be palpated. The lymph nodes maybe central or peripheral located deep in the subcutaneous tissue. Common causes of lymphadenopathy include infectious and non-infectious. A thorough physical exam is important to establish a differential diagnosis. The common causes of lymphadenopathy can be remembered using pneumonic CHICAGO (Cancer, Hypersensitivity, Infection, Connective tissue disorders, Atypical lymphoproliferative disorders, Granulomatous, and Others). Excisional biopsy is the gold standard for tissue diagnosis. Infections can be treated with antibiotics while cancers require surgical resection, staging and chemotherapy or radiotherapy.
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
The American Academy of Family Physicians (AAFP) and many research articles utilize a pneumonic CHICAGO to include all causes of lymphadenopathy based on etiology. The causes may also be remembered based on the location of lymph nodes.
- Hypersensitivity :
- Fungal, Protozoan, Rickettsial (Typhus), Helminthes.
- Bacterial: Tiberculosis, syphilis (primary and secondary), chancroid, staphylococcus or streptococcal skin infections.
- Viral: IM, CMV, HIV,lymphadenitis post vaccination, adenovirus, herpes zoster, and hepatitis (infectious), and melioidosis.
- Chlamydial (lymphogranuloma venereum), protozoan (toxoplasmosis), mycotic (histoplasmosis, coccidioidomycosis, helminthic (filariasis, and rickettsial (typhus).
- Connective tissue disorders:
- Atypical lymphoproliferative disorders :
- For more detailed information in the causes of lymphadenopathy, click here.
Diagnostic algorithm and management
Abbreviations: UVUltraviolet rays; UTIUrinary tract infection; HEENT: Head, Eyes, Ears. Nose, and Throat exam; IM: Infectious Mononucleosis; L.N: Lymph node;CBC: Complete blood count; ESR: Erythrocyte sedimentation rate; CMP: Comprehensive metabolic panel; LFTs:Liver function tests; URTI: Upper respiratory tract infection; CMV: Cytomegalovirus; IgM: Immuniglobulin M; IgG:Immunoglobuin G; ANA:Antinuclear antibodies; CXR:Chest X-ray; CT: CT scan; VDRL: Venereal disease research laboratory; RPR:Reactive plasma reagen
Appearance of the patient
Cachexia or surgical scar marks demonstrating previous malignancy treatment
❑ Extremities exam
|Palpable lymph node|
❑ Location: (Localized vs generalized)
❑ Tenderness or pain:
|Suggests infection/ serious infection||Unexplained||Suggests malignancy|
May require specific tests
❑ Throat swab
|Perform specific tests||Risk factors for malignancy|
Family history, age, exposure, etc
|Perform specific tests|
|Low risk||High risk|
Specific tests/ biopsy
|Review history and clues suggesting malignancy||Positive||Treat|
❑ Specific tests
such as CXR, ultrasound, CT, lab workup, biopsy.
|Observe 3-4 weeks|
- The table describes possible infectious and oncologic differential diagnoses based upon the location of lymphadenopathy. Please click on the disease name in the management section for a detailed review of the medical therapy utilized in the management of the specific entity. Please click on the disease name in other columns for a detailed review of the disease in general.
|Region||Lymphadenopathy||Infections||Malignancies||Management (click on disease name to read about the treatment)|
|Head and neck||Preauricular and posterior cervical|
|Submandibular and anterior cervical|
|Axillary||Infraclavicular||Non-Hodgkin's lymphoma||Non-Hodgkin lymphoma|
|Superficial inguinal||Horizontal and vertical|
- The table describes possible differential diagnoses of generalized lymphadenopathy based upon the cause. Please click on the disease name in the management section for a detailed review of the medical therapy utilized in the management of the specific entity. Please click on the disease name in other columns for a detailed review of the disease in general.
|Autoimmune||Drug reactions||Infections||Malignancies||Storage disorders||Management (click on disease name to read about the treatment)|
- TNM stands for Tumor, Nodes, and Metastasis. The TNM staging system is widely utilized in staging tumors, especially solid tumors. For a detailed review of the TNM staging system please click here.
- For a detailed review of the staging systems utilized in cancer management please click here.
- Ann Arbor staging is utilized to stage lymphomas. Pleaseclick here for a detailed review on the staging system.
- Patients with immunodeficiency should have a wide differential diagnosis considering non-Hodgkin's lymphoma and Kaposi sarcoma.
- Remember that lymphadenopathy involving supraclavicular L.N poses the highest risk of malignancy (90% among patients >40 years of age) and 25% among < 40 years old. 
- Needle aspiration biopsy or excisional biopsy is the gold standard for the tissue diagnosis and evaluation for lymphadenopathy.
- When lymphadenopathy is present, it is important to examine the whole area of lymphatic drainage of the particular organ. For example, examining the region beneath the umbilicus in case of inguinal lymphadenopathy.
- Physical examination should never be missed as a finding may change the course of differential diagnosis. Missing the physical exam may lead to unnecessary investigations and delays.
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- "Tips From Other Journals - American Family Physician".
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