LIMFADENITIS

Nurul Aini Yudita

1110311001

Pathophysiology of Lymphadenopathy

Initial Infection

Pharyngitis / Otitis Media / Odontogenic infection

Lymphatic drainage

Presentation to T cells

Proliferation of clonal cells

Release of cytokines leading to chemotaxis

Activation of B cells

Immunoglobulin release

Continued proliferation of immune response

Pathophysiology Contd

Results of the Immune Response

Cellular Hyperplasia
Leukocyte Infiltration
Tissue Edema
Vasodilation and Capillary Leak
Tenderness due to capsule distension

DD

Congenital Masses

Malignancies

Local presentation of systemic disease

Other

Differential Diagnosis
Congenital Masses

Thyroglossal duct cyst

Dermoid Cyst

Transilluminates and is compressible

Sternocleidomastoid Tumor

Mass is presents after birth, rapidly grows, plateaus, and is red or bluish
in color

Cystic Hygroma

Enlarges with valsalva

Hemangioma

Smooth and fluctuant along SCM border

Laryngocele

Midline and often has calcifications on plain films

Branchial Cleft Cyst

Moves with tongue protrusion and is midline

Lymphadenopathy does not present with torticollis

Cervical Ribs

Bilateral, hard and immobile

Malignancies

Lymphoma
Hodgkin's

lymphoma
Non-Hodgkin's lymphoma

Leukemia
CLL

Lung (mediastinal)
Metastatic: breast, melanoma
(Usually axillary), SCC

Differential Diagnosis
Systemic diseases

Viral - Most common form

Often bilateral, diffuse, non-tender
Other Signs/Symptoms are consistent with URI

Mumps parotis, not lymph node

EBV, CMV

Adenovirus
Other

Differential Diagnosis
Systemic diseases

Bartonella

Toxoplasmosis

STDs

Kawasaki disease

MUMPS

Painful swelling,
superior to jaw line

Uni or bilateral

Epidemic

Vaccinated?

Look for orchitis

Sometimes meningitis

Infectious Mononucleosis
EBV, CMV

Fever

Sore throat

Hepatosplenomegaly

Lymphocytosis

Suppurative Bacterial
Lymphadenitis

Staphylococcus aureus and Group A Streptococcus

Anaerobes

Usually acute onset, fever, CBC

Management: antibiotics (which one?)

If not resolving or getting worse

Ultrasound and/or CT with contrast to evaluate for

phlegmon/abscess/infiltrate

FNA vs Surgical I&D vs Surgical Excision if abscess is

identified

Suppurative Lymphadenitis with

Overlying cellulitis

Subacute Lymphadenitis

2-6 weeks

Usually no improvement with antibiotics

DD:

Atypical Mycobacteria

Cat Scratch disease

Toxoplasmosis

TB

Atypical Mycobacteria

Leading cause of sub-acute disease

Species involved:

Mycobacterium avium-intrucellulare

Mycobacterium scrofulaceum

Develops over weeks to months

Lymph nodes may have violaceous skin over the node

No fever, normal behavior, no pain

Diagnosis: acid fast stain and culture, can take weeks. PCR.

Treatment: surgical excision of involved lymph nodes, some offer

antibiotics (Clarithromycin plus Rifabutin)

Tuberculosis
lymphadenitis (Scrofula)
Presenting Signs and Symptoms
Cervical nodes most commonly involved
Firm, discrete nodes

Fluctuant nodes

Skin breakdown, abscesses, chronic sinuses

healing and scarring

Tuberculosis (Scrofula)

Approach to lymphadenitis

History

Fever, malaise, anorexia, myalgias

Pain or tenderness of node

Sore Throat / Toothache / Ear pain

Insect Bites

Exposure to animals

History of travel or exposure to TB

Immunizations

Medications

Physical Exam

General

Skin

Size
Unilateral vs Bilateral
Tender vs Nontender
Mobile vs Fixed
Hard vs Soft

Lungs

Otitis, pharyngitis, teeth, and nasal cavity

Neck

Cellulitis, impetigo, rash

ENT

Febrile or toxic appearing

Consolidations suggesting TB

Abdomen

Hepatosplenomegaly

Laboratory Workup

CBC with Differential

ESR

Throat culture

Serology

EBV, CMV, Toxoplasmosis, Bartonella, Syphilis, HIV

PPD

LDH, uric acid

Imaging Workup

CXR if malignancy sus.

Ultrasound

To evaluate for abscess

EKG/ECHO

Abscess?
Benign vs. malignant

Sometimes CT/MRI

To look for mediastinal lymphadenopathy

If suspect Kawasaki Disease

Biopsy

FNA or Excisional

Summary

History and Physical exam

Further workup with serology, imaging, and biopsy with

resistant, subacute and chronic cases

Ultrasound is a useful to characterize and differentiate

reactive, suppurative, and malignant lymph nodes

Sometimes Biopsy

The end