Sandbox: Lymphadenopathy: Difference between revisions

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==Overview==
==Overview==
'''Lymphadenopathy''' (also known as "enlarged lymph nodes) refers to [[lymph nodes]] which are abnormal in size, number or consistency. Common causes of lymphadenopathy are [[infection]], [[autoimmune]] disease, or [[malignancy]].<ref name="!">{{cite journal|last=King|first=D|last2=Ramachandra|first2=J|last3=Yeomanson|first3=D|title=Lymphadenopathy in children: refer or reassure?|journal=Archives of Disease in Childhood: Education and Practice Edition|date=2 January 2014|pmid=24385291|doi=10.1136/archdischild-2013-304443|volume=99|pages=101–110}}</ref>  Lymphadenopathy may be classified according to distribution into 2 groups: generalized lymphadenopathy and localized lymphadenopathy. The pathogenesis of lymphadenopathy is characterized by the inflammation of lymph nodes. This process is primarily due to an elevated rate of trafficking of [[lymphocytes]] into the node from the blood, exceeding the rate of outflow from the node. Lymph nodes may also be enlarged secondarily as a result of the activation and proliferation of antigen-specific T and [[B cells]] (clonal expansion). Lymphadenopathy is very common,  the estimated incidence of lymphadenopathy among children in the United States ranges from 35%- 45%.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref> Patients of all age groups may develop lymphadenopathy. Lymphadenopathy is more commonly observed among children. Common complications of lymphadenopathy, may include: [[Abscess|abscess formation]], [[superior vena cava syndrome]], and [[intestinal obstruction]].  Diagnostic criteria for malignant lymphadenopathy, may include: node > 2 cm, node that is draining, hard, or fixed to underlying tissue, atypical location (e.g. supraclavicular node), associated risk factors (e.g. [[HIV AIDS|HIV]] or [[Tuberculosis|TB]]), fever and/or weight loss, and splenomegaly. On the other hand, diagnostic criteria for benign lymphadenopathy, may include: node < 1 cm, node that is mobile, soft-or tender, and is not fixed to underlying tissue, typical location (e.g. supraclavicular node), no associated risk factors, and palpable and painful enlargement. Laboratory findings consistent with the diagnosis of lymphadenopathy, may include: elevated lactate dehydrogenase (LDH), mild neutropenia, and [[leukocytosis]]. There is no treatment for lymphadenopathy; the mainstay of therapy is treating the underlying condition.


==Classification==
*Lymphadenopathy may be classified according to distribution into 2 groups:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
:*Generalized lymphadenopathy
:*Localized lymphadenopathy


==Historical Perspective==
*[Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
*In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
*In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
==Classification==
*[Disease name] may be classified according to [classification method] into [number] subtypes/groups:
:*[group1]
:*[group2]
:*[group3]
*Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].
==Pathophysiology==
==Pathophysiology==
*The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
*The pathogenesis of lymphadenopathy is characterized by the inflammation of lymph nodes. This process is primarily due to an elevated rate of trafficking of lymphocytes into the node from the blood, exceeding the rate of outflow from the node.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
*The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
*The inmune response between the antigen and lymphocyte that leads to cellular proliferation and enlargement of the lymph nodes.
*On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
*Lymph nodes may also be enlarged secondarily as a result of the activation and proliferation of antigen-specific T and B cells (clonal expansion).  
*On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
*On gross pathology, characteristic findings of lymphadenopathy, include:
:*Enlarged lymph node
:*Soft greasy yellow areas within capsule
*On microscopic histopathological analysis, characteristic findings of lymphadenopathy will depend on the aetiology.
*Common findings, include:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
'''Non-specific reactive follicular hyperplasia (NSRFH)'''
:*Large spaced cortical follicles
:*Tingible body macrophages, normal dark/light GC pattern
'''Lymph node metastasis'''
:*Foreign cell population (usually in subcapsular sinuses)
:*+/-nuclear atypia
:* +/-malignant architecture
'''Toxoplasmosis'''
:*Large follicles
:*Epithelioid cells perifollicular & intrafollicular
:*Reactive GCs
:*Monocytoid cell clusters
'''Cat-scratch disease'''
:*PMNs in necrotic area
:*"Stellate" (or serpentine) shaped micro-abscesses
:*Presence of granulomas
'''Dermatopathic lymphadenopathy'''
:*Melanin-laden histiocytes
:*Histiocytosis
'''Systemic lupus erythematosus lymphadenopathy'''
:*Blue hematoxylin bodies
:*Necrosis
:*No PMNs
 
==Causes==
==Causes==
* [Disease name] may be caused by either [cause1], [cause2], or [cause3].
*Common causes of lymphadenopathy, include:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
* [Disease name] is caused by a mutation in the [gene1], [gene2], or [gene3] gene[s].
:*'''Infections''' (acute suppurative)
* There are no established causes for [disease name].
::*Fungal
::*Mycobacterial
==Differentiating [disease name] from other Diseases==
::*Viral
*[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:
::*Protozoal (e.g. [[Toxoplasmosis|toxoplasma]])
:*[Differential dx1]
::*Bacterial (e.g. [[chlamydia]], [[Rickettsia rickettsii infection|rickettsia]], [[bartonella]])
:*[Differential dx2]
:*'''Reactive'''
:*[Differential dx3]
::*Follicular hyperplasia
::*Paracortical hyperplasia
::*Sinus histiocytosis
::*Granulomatous
::*Neoplastic
::*Drugs (e.g. cyclosporin, phenytoin, methotrexate)
::*Lipid storage diseases
::*IgG4-related sclerosing disease
 
==Epidemiology and Demographics==
==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* Lymphadenopathy is very common.  
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
*The estimated incidence of lymphadenopathy among children in the United States ranges from 35%- 45%.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
===Age===
===Age===
*Patients of all age groups may develop [disease name].
*Patients of all age groups may develop lymphadenopathy.
*Lymphadenopathy is more commonly observed among children.
*[Disease name] is more commonly observed among patients aged [age range] years old.
 
*[Disease name] is more commonly observed among [elderly patients/young patients/children].
===Gender===
===Gender===
*[Disease name] affects men and women equally.
*Lymphadenopathy affects men and women equally.
*[Gender 1] are more commonly affected with [disease name] than [gender 2].
* The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.
   
   
===Race===
===Race===
*There is no racial predilection for [disease name].
*There is no racial predilection for lymphadenopathy.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
 
*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].
==Risk Factors==
==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
*The most common risk factors in the development of lymphadenopathy, include:
:*Local soft-tissue infections
:*[[Upper respiratory tract infection]]
:*Foreign travel
 
== Natural History, Complications and Prognosis==
== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Patients with lymphadenopathy may be symptomatic or asymptomatic, depending on the aetiology.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref> 
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*Early clinical features include palpable tenderness, pain, and fever.
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of lymphadenopathy, include:
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
 
*Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].
'''Mediastinal lymphadenopathy'''
* [[Superior vena cava syndrome]]
** Tracheal and bronchial obstruction
** [[Dysphagia]]
** [[Hemoptysis]]
* [[Uric acid nephropathy]]
* [[Hyperkalemia]]
* [[Hypercalcemia]]
* [[Hypocalcemia]]
* [[Hyperphosphatemia]]
* [[Renal failure]]
'''Abdominal lymphadenopathy'''
* [[Intestinal obstruction]]
'''Superficial lymphadenopathy'''
* [[Abscess]] formation
* [[Cellulitis]]  
* [[Fistulas]] (seen in lymphadenitis that is due to [[tuberculosis]])
* [[Sepsis]]  
*Prognosis will depend on the aetiology of the underlying disease.
 
== Diagnosis ==
== Diagnosis ==
===Diagnostic Criteria===
===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
====Malignant Lymphadenopathy====
:*[criterion 1]
:*Node > 2 cm
:*[criterion 2]
:*Node that is draining, hard, or fixed to underlying tissue
:*[criterion 3]
:*Atypical location (e.g. supraclavicular node)
:*[criterion 4]
:*Risk factors (e.g. [[HIV AIDS|HIV]] or [[TB]])
:*Fever and/or weight loss
:*[[Splenomegaly]]
 
====Benign Lymphadenopathy====
:*Node < 1 cm
:*Node that is mobile, soft-or tender, and is not fixed to underlying tissue
:*Common location (e.g. supraclavicular node)
:*No associated risk factors
:*Palpable and painful enlargement
 
=== Symptoms ===
=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of lymphadenopathy may include the following:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
*Symptoms of [disease name] may include the following:
:*'''Constitutional symptoms'''
:*[symptom 1]
::*[[Fever]]
:*[symptom 2]
::*[[Weight loss]]
:*[symptom 3]
::*[[Fatigue]]  
:*[symptom 4]
::*[[Night sweats]]
:*[symptom 5]
:* [[Malaise]]
:*[symptom 6]
:* [[Nausea]] and [[vomiting]]
:* [[Cachexia]]
*A directed history should be obtained to ascertain:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
:*Use of drugs causing lymphadenopathy
:*Travel to endemic areas
:*Occupational risk (e.g. Fishermen, slaughterhouse workers, hunters, trappers)
:*High risk behavior or high risk sexual behaviors (e.g. I.V drug abuse, multiple partners)
 
=== Physical Examination ===
=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Patients with lymphadenopathy may have a pale or normal appearance.  
*Physical examination may be remarkable for:
*Physical examination may be remarkable for:
:*[finding 1]
===Vitals===
:*[finding 2]
* Temperature
:*[finding 3]
:*High grade fever
:*[finding 4]
:*Low grade fever
:*[finding 5]
* Pulse
:*[finding 6]
:*Rapid (e.g. acute infections)
===Skin===
* [[Rash]] may be present
* Color change (indicative of inflammation)
* Skin [[fistula]] draining pus may be present
* Ulcers
 
===Head===
====Palpating Anterior Cervical Lymph Nodes====
Lymph nodes should be examined in the following order:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref> 
*Anterior Cervical
*Posterior Cervical
* Tonsillar
* Sub-Mandibular
*Sub-Mental
* Supra-clavicular
 
Characteristics to be noted while palpating lymph nodes:
* Size
* Pain/ tenderness
:*Increased tenderness (e.g infected lymph nodes)
* Consistency
* Matting
 
====Gallery====
====Gallery====


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<gallery heights="175" widths="175">
<gallery heights="175" widths="175">
Image:head_scc1.jpg|'''Cervical adenopathy''': massive right side cervical adenopathy and facial asymmetry due to metastatic, intraoral squamous cell cancer. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
Image:head_scc1.jpg|'''Cervical adenopathy''': massive right side cervical adenopathy and facial asymmetry due to metastatic, intraoral squamous cell cancer. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
Image:head_scc2.jpg|'''Cervical adenopathy''': massive right side cervical adenopathy and facial asymmetry due to metastatic, intraoral squamous cell cancer.  Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.I
Image:head_scc2.jpg|'''Cervical adenopathy''': massive right side cervical adenopathy and facial asymmetry due to metastatic, intraoral squamous cell cancer.  Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
Image:head_cervical_ln.jpg|'''Cervical adenopathy''': large right anterior cervical lymph node.  Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
Image:head_cervical_ln.jpg|'''Cervical adenopathy''': large right anterior cervical lymph node.  Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
Image: Lymphadenopathy 001.jpg| '''Cervical lymphadenopathy'''. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
Image: Lymphadenopathy 001.jpg| '''Cervical lymphadenopathy'''. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
Line 109: Line 186:


=== Laboratory Findings ===
=== Laboratory Findings ===
*There are no specific laboratory findings associated with [disease name].
*Laboratory findings consistent with the diagnosis of lymphadenopathy, may include:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
'''Complete Blood Count'''
:*Elevated lactate dehydrogenase (LDH)
:*Mild neutropenia
:*Leukocytosis
:*Elevated markers of inflammation and acute phase reactants (e.g. ESR, C-reactive protein, ferritin)


*A  [positive/negative] [test name] is diagnostic of [disease name].
*An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
*Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
===Imaging Findings===
===Imaging Findings===
*There are no [imaging study] findings associated with [disease name].
'''Ultrasonography'''
   
*On ultrasound, characteristic findings of lymphadenopathy, include:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="radio">Lymph node enlargment. Radiopedia.  http://radiopaedia.org/articles/lymph-node-enlargement Accessed on May 9, 2016 </ref>
*[Imaging study 1] is the imaging modality of choice for [disease name].
:*Round, hypoechoic mass (less than 1 cm)
*On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
:*Extent of lymph node involvement
*[Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].
'''CT'''
*On CT, characteristic findings of lymphadenopathy, include:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="radio">Lymph node enlargment. Radiopedia.  http://radiopaedia.org/articles/lymph-node-enlargement Accessed on May 9, 2016 </ref>
=== Other Diagnostic Studies ===
:*Most nodes: 10 mm in short-axis
*[Disease name] may also be diagnosed using [diagnostic study name].
:*Sub-mental and sub-mandibular: 15 mm
*Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].
:*Retropharyngeal: 8 mm
:*Loss of fatty hilum
:*Focal necrosis
:*Cystic necrotic nodes
:*Long-to-short axis ratio (>2cm - usually benign)
*The upper limit in size of a normal node varies with location.
 
== Treatment ==
== Treatment ==
=== Medical Therapy ===
*There is no treatment for lymphadenopathy; the mainstay of therapy is treating the underlying condition.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
*For instance, infectious lymphadenopathy responds well to prompt treatment with antibiotics, and usually leads to a complete recovery. However, it may take months, for swelling to disappear. The amount of time to recovery depends on the cause.
*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
=== Prevention ===
*There are no primary preventive measures available for [disease name].
*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].


*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
   
   
[[Category: Oncology]]
[[Category: Oncology]]

Latest revision as of 19:23, 9 May 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Synonyms and keywords: Lymph nodes enlarged; Enlarged lymph nodes; Lymphadenitis; Swollen lymph nodes; Swollen/enlarged lymph nodes

Overview

Lymphadenopathy (also known as "enlarged lymph nodes) refers to lymph nodes which are abnormal in size, number or consistency. Common causes of lymphadenopathy are infection, autoimmune disease, or malignancy.[1] Lymphadenopathy may be classified according to distribution into 2 groups: generalized lymphadenopathy and localized lymphadenopathy. The pathogenesis of lymphadenopathy is characterized by the inflammation of lymph nodes. This process is primarily due to an elevated rate of trafficking of lymphocytes into the node from the blood, exceeding the rate of outflow from the node. Lymph nodes may also be enlarged secondarily as a result of the activation and proliferation of antigen-specific T and B cells (clonal expansion). Lymphadenopathy is very common, the estimated incidence of lymphadenopathy among children in the United States ranges from 35%- 45%.[2] Patients of all age groups may develop lymphadenopathy. Lymphadenopathy is more commonly observed among children. Common complications of lymphadenopathy, may include: abscess formation, superior vena cava syndrome, and intestinal obstruction. Diagnostic criteria for malignant lymphadenopathy, may include: node > 2 cm, node that is draining, hard, or fixed to underlying tissue, atypical location (e.g. supraclavicular node), associated risk factors (e.g. HIV or TB), fever and/or weight loss, and splenomegaly. On the other hand, diagnostic criteria for benign lymphadenopathy, may include: node < 1 cm, node that is mobile, soft-or tender, and is not fixed to underlying tissue, typical location (e.g. supraclavicular node), no associated risk factors, and palpable and painful enlargement. Laboratory findings consistent with the diagnosis of lymphadenopathy, may include: elevated lactate dehydrogenase (LDH), mild neutropenia, and leukocytosis. There is no treatment for lymphadenopathy; the mainstay of therapy is treating the underlying condition.

Classification

  • Lymphadenopathy may be classified according to distribution into 2 groups:[2]
  • Generalized lymphadenopathy
  • Localized lymphadenopathy

Pathophysiology

  • The pathogenesis of lymphadenopathy is characterized by the inflammation of lymph nodes. This process is primarily due to an elevated rate of trafficking of lymphocytes into the node from the blood, exceeding the rate of outflow from the node.[2]
  • The inmune response between the antigen and lymphocyte that leads to cellular proliferation and enlargement of the lymph nodes.
  • Lymph nodes may also be enlarged secondarily as a result of the activation and proliferation of antigen-specific T and B cells (clonal expansion).
  • On gross pathology, characteristic findings of lymphadenopathy, include:
  • Enlarged lymph node
  • Soft greasy yellow areas within capsule
  • On microscopic histopathological analysis, characteristic findings of lymphadenopathy will depend on the aetiology.
  • Common findings, include:[2]

Non-specific reactive follicular hyperplasia (NSRFH)

  • Large spaced cortical follicles
  • Tingible body macrophages, normal dark/light GC pattern

Lymph node metastasis

  • Foreign cell population (usually in subcapsular sinuses)
  • +/-nuclear atypia
  • +/-malignant architecture

Toxoplasmosis

  • Large follicles
  • Epithelioid cells perifollicular & intrafollicular
  • Reactive GCs
  • Monocytoid cell clusters

Cat-scratch disease

  • PMNs in necrotic area
  • "Stellate" (or serpentine) shaped micro-abscesses
  • Presence of granulomas

Dermatopathic lymphadenopathy

  • Melanin-laden histiocytes
  • Histiocytosis

Systemic lupus erythematosus lymphadenopathy

  • Blue hematoxylin bodies
  • Necrosis
  • No PMNs

Causes

  • Common causes of lymphadenopathy, include:[2]
  • Infections (acute suppurative)
  • Reactive
  • Follicular hyperplasia
  • Paracortical hyperplasia
  • Sinus histiocytosis
  • Granulomatous
  • Neoplastic
  • Drugs (e.g. cyclosporin, phenytoin, methotrexate)
  • Lipid storage diseases
  • IgG4-related sclerosing disease

Epidemiology and Demographics

  • Lymphadenopathy is very common.
  • The estimated incidence of lymphadenopathy among children in the United States ranges from 35%- 45%.[2]

Age

  • Patients of all age groups may develop lymphadenopathy.
  • Lymphadenopathy is more commonly observed among children.

Gender

  • Lymphadenopathy affects men and women equally.

Race

  • There is no racial predilection for lymphadenopathy.[2]

Risk Factors

  • The most common risk factors in the development of lymphadenopathy, include:

Natural History, Complications and Prognosis

  • Patients with lymphadenopathy may be symptomatic or asymptomatic, depending on the aetiology.[2]
  • Early clinical features include palpable tenderness, pain, and fever.
  • Common complications of lymphadenopathy, include:

Mediastinal lymphadenopathy

Abdominal lymphadenopathy

Superficial lymphadenopathy

Diagnosis

Diagnostic Criteria

Malignant Lymphadenopathy

  • Node > 2 cm
  • Node that is draining, hard, or fixed to underlying tissue
  • Atypical location (e.g. supraclavicular node)
  • Risk factors (e.g. HIV or TB)
  • Fever and/or weight loss
  • Splenomegaly

Benign Lymphadenopathy

  • Node < 1 cm
  • Node that is mobile, soft-or tender, and is not fixed to underlying tissue
  • Common location (e.g. supraclavicular node)
  • No associated risk factors
  • Palpable and painful enlargement

Symptoms

  • Symptoms of lymphadenopathy may include the following:[2]
  • Constitutional symptoms
  • A directed history should be obtained to ascertain:[2]
  • Use of drugs causing lymphadenopathy
  • Travel to endemic areas
  • Occupational risk (e.g. Fishermen, slaughterhouse workers, hunters, trappers)
  • High risk behavior or high risk sexual behaviors (e.g. I.V drug abuse, multiple partners)

Physical Examination

  • Patients with lymphadenopathy may have a pale or normal appearance.
  • Physical examination may be remarkable for:

Vitals

  • Temperature
  • High grade fever
  • Low grade fever
  • Pulse
  • Rapid (e.g. acute infections)

Skin

  • Rash may be present
  • Color change (indicative of inflammation)
  • Skin fistula draining pus may be present
  • Ulcers

Head

Palpating Anterior Cervical Lymph Nodes

Lymph nodes should be examined in the following order:[2]

  • Anterior Cervical
  • Posterior Cervical
  • Tonsillar
  • Sub-Mandibular
  • Sub-Mental
  • Supra-clavicular

Characteristics to be noted while palpating lymph nodes:

  • Size
  • Pain/ tenderness
  • Increased tenderness (e.g infected lymph nodes)
  • Consistency
  • Matting

Gallery

  • Cervical adenopathy: massive right side cervical adenopathy and facial asymmetry due to metastatic, intraoral squamous cell cancer. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.

    Cervical adenopathy: massive right side cervical adenopathy and facial asymmetry due to metastatic, intraoral squamous cell cancer. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.

  • Cervical adenopathy: massive right side cervical adenopathy and facial asymmetry due to metastatic, intraoral squamous cell cancer. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.

    Cervical adenopathy: massive right side cervical adenopathy and facial asymmetry due to metastatic, intraoral squamous cell cancer. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.

  • Cervical adenopathy: large right anterior cervical lymph node. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.

    Cervical adenopathy: large right anterior cervical lymph node. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.

  • Cervical lymphadenopathy. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.

    Cervical lymphadenopathy. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.

  • Cervical Adenopathy: multiple right sided cervical lymph nodes. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.

    Cervical Adenopathy: multiple right sided cervical lymph nodes. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.

Laboratory Findings

  • Laboratory findings consistent with the diagnosis of lymphadenopathy, may include:[2]

Complete Blood Count

  • Elevated lactate dehydrogenase (LDH)
  • Mild neutropenia
  • Leukocytosis
  • Elevated markers of inflammation and acute phase reactants (e.g. ESR, C-reactive protein, ferritin)

Imaging Findings

Ultrasonography

  • On ultrasound, characteristic findings of lymphadenopathy, include:[2][3]
  • Round, hypoechoic mass (less than 1 cm)
  • Extent of lymph node involvement

CT

  • On CT, characteristic findings of lymphadenopathy, include:[2][3]
  • Most nodes: 10 mm in short-axis
  • Sub-mental and sub-mandibular: 15 mm
  • Retropharyngeal: 8 mm
  • Loss of fatty hilum
  • Focal necrosis
  • Cystic necrotic nodes
  • Long-to-short axis ratio (>2cm - usually benign)
  • The upper limit in size of a normal node varies with location.

Treatment

  • There is no treatment for lymphadenopathy; the mainstay of therapy is treating the underlying condition.[2]
  • For instance, infectious lymphadenopathy responds well to prompt treatment with antibiotics, and usually leads to a complete recovery. However, it may take months, for swelling to disappear. The amount of time to recovery depends on the cause.

References

  1. ↑ King, D; Ramachandra, J; Yeomanson, D (2 January 2014). "Lymphadenopathy in children: refer or reassure?". Archives of Disease in Childhood: Education and Practice Edition. 99: 101–110. doi:10.1136/archdischild-2013-304443. PMID 24385291.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A (2014). "Peripheral lymphadenopathy: approach and diagnostic tools". Iran J Med Sci. 39 (2 Suppl): 158–70. PMC 3993046. PMID 24753638.
  3. ↑ 3.0 3.1 Lymph node enlargment. Radiopedia. http://radiopaedia.org/articles/lymph-node-enlargement Accessed on May 9, 2016
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