Sandbox: Lymphadenopathy

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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

Historical Perspective

  • Lymphadenopathy 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 lymphadenopathy.
  • In [year], the first [discovery] was developed by [scientist] to treat/diagnose lymphadenopathy.

Classification

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

Pathophysiology

  • The pathogenesis of lymphadenopathy is characterized by [feature1], [feature2], and [feature3].
  • On gross pathology, characteristic findings of lymphadenopathy, include:
  • On microscopic histopathological analysis, characteristic findings of lymphadenopathy will depend on the aetiology.
  • Common findings, include:

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:
  • Infections (acute suppurative)
  • Fungal
  • Mycobacterial
  • Viral
  • Protozoal (e.g. toxoplasma)
  • Bacterial (e.g. chlamydia, rickettsia, bartonella)
  • 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 prevalence of lymphadenopathy is approximately [number or range] per 100,000 individuals worldwide.

Age

  • Patients of all age groups may develop lymphadenopathy.

Gender

  • Lymphadenopathy affects men and women equally.

Race

  • There is no racial predilection for lymphadenopathy.

Risk Factors

  • Common risk factors in the development of lymphadenopathy are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

Natural History, Complications and Prognosis

  • The majority of patients with lymphadenopathy remain asymptomatic for [duration/years].
  • Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
  • If left untreated, [#%] of patients with lymphadenopathy may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
  • Common complications of lymphadenopathy 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 lymphadenopathy is approximately [#%].

Diagnosis

Diagnostic Criteria

  • The diagnosis of lymphadenopathy is made when at least [number] of the following [number] diagnostic criteria are met:
  • [criterion 1]
  • [criterion 2]
  • [criterion 3]
  • [criterion 4]

Symptoms

  • Symptoms of lymphadenopathy may include the following:
  • Constitutional symptoms
  • Fever
  • Weight loss
  • Fatigue
  • Night sweats
  • A directed history should be obtained to ascertain:
  • 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:

  • 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

Laboratory Findings

  • There are no specific laboratory findings associated with [disease name].
  • 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

  • There are no [imaging study] findings associated with [disease name].
  • [Imaging study 1] is the imaging modality of choice for [disease name].
  • On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
  • [Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

  • [Disease name] may also be diagnosed using [diagnostic study name].
  • Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

  • There is no treatment for [disease name]; the mainstay of therapy is supportive care.
  • 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