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Lymphadenopathy
Ashley Rosko, MD
Case
41 yo male school teacher presents to your office with right sided
cervical lymphadenopathy. His past medical history is significant
for hypertension and dyslipidemia. His medications include hctz
and simvastatin. NKDA. He noticed the lump in his neck last week.
He has not experienced any fevers, chills or weight loss. He
denies any sore throat, ear pain or dental problems. His vital signs
are stable. On physical exam he has a 2cm anterior cervical lymph
node which is firm, non-tender and mobile. His HEENT exam is
unremarkable. No skin lesions are evident. No other
lymphadenopathy is found. How should you proceed with this
patient?
A. Location and duration typical for viral etiology. Have your patient
follow up for annual physical next year.
B. Proceed to fine needle aspiration.
C. Check a CXR and cbc.
D. Have patient follow up in 3-4 weeks.
Learning Objectives
Provide an approach to the patient with
peripheral lymphadenopathy
Be able to differentiate between benign and
serious illness
Knowledgeable of nodal distribution and
anatomic drainage
Present a substantial differential diagnosis
Localized
Lymphatic System
Network that filters antigens from the interstitial fluid
Primary site of immune response from tissue
antigens
Lymphatic drainage in all organs of the body except
brain, eyes, marrow and cartilage
Flaccid thin walled channelsprogressive caliber
600 lymph nodes in body
Slow flow, low pressure system returns interstitial
fluid to the blood system
Secondary lymphoid tissue
Lymph nodes
Capsular shell
Fibroblasts and reticulin
fibers
Macrophages
Dendritic cells
T cells
B cells
Peripheral lymphadenopathy
Most cases benign, self limited illness
Primary or secondary manifestation of 100
illnesses
The CHALLENGE is to decide if it is
representative of a serious illness
Parameters to help
distinguish between
benign and serious
illness
Age
Character
Location
Malignancy much more
common in patients
greater 50 yrs of age
Not exactly
Epidemiology
Lee et al 1980 Referral centers 925
underwent a lymph node biopsy.
Age <30 79% benign 15% lymphomatous
6% carcinomas
Age >50 40% benign 16% lymphomatous
44% carcinomas
Age 30-50 indeterminate values
Dutch study Fijten 1988
0.6 annual incidence of generalized
lymphadenopathy
2,556 present with unexplained
lymphadenopathy
10% referred to subspecialist3.2% required
bx and of that 1.1% had a malignancy
40 yrs + 4% risk of cancer vs. 0.4% risk in pts
younger than 40
Lymph node character
Size
Site
Consistency
Matting
Location, location, location
Post cervical: scalp, neck skin of arms thorax cervi cal and axillary nodes (lymphoma, head/neck ca)
Supraclavicular Nodes
Drain the mediastinum and abdomen
Hodgkin, NHL
Melanoma (drains back of arm)
Staph/strep
Cat scratch
Silicone prosthesis
Inguinal lymphadenopathy
Drain
the lower extremity, genitalia, buttocks,
abdominal wall
Normal
Venereal disease
Epitrochlear
Lymphoma/CLL
Mono
Virchows
Left supraclavicular (abdominal or thoracic ca)
Sister Joseph
CHICAGO
Chicago
Cancer
Heme malignancies: Hodgkins, NHL, acute
and chronic leukemias, waldenstroms,
multiple myeloma (plastmocytomas)
Metastatic: solid tumor breast, lung, renal,
cell ovarian
cH icago
Hypersensitivity syndromes
Serum sickness Drugs
Serum sickness like Silicone
illness Vaccination
Graft vs Host
Specific Medications
Cephalosporins Dilantin
Atenolol Sulfonamides
Captopril Carbamazepine
Primodine
Gold
Allupurinol
i
Ch cago
Infections
Viral
Bacterial
Protozoan
Mycotic
Rickettsial(typhus)
Helminthic (filariasis)
VIRAL
EBVmono spot test
CMV.cmv titers, immunsuppresed,
transplant recipient, recent blood transfusion
HIVIV drug use, high risk sexual behavior
Spirochete
Syphilis:Treponema pallidum Primary
localized inguinal lymph nodes and
secondary, non-treponemal, treponemal
Lyme disease
Protozoan
Toxoplasmosis:ELISA assay, intracellular
protozoan toxoplasmosis gondii.bilateral,
symmetrical, non-tender cervical adenopathy
consider undercooked meat, reactivation in
immuncompromised host
chi cago
Connective Tissue Disease
Rheumatoid Arthritis
SLE
Dermatomyositis
Atypical lymphoproliferative
disorders
Castlemans disease
Wegeners
Granulomatous
Histoplasmosis
Mycobacterial infections
Cryptococcus
Cat Scratch
My cat Pigeon
OTHER.chicago
RARE
Kikuchi
Rosia Dorfman
Kawasaki
Review Medications