Pendekatan Diagnostik

Limfadenopati :
Limfadenopati dan
pendekatan diagnostik
Limfadenitis

Dr. Norman Djamaluddin, SpPD K- HOM

Sub bagian Hematologi Onkologi Medik
Bagian Penyakit Dalam RSMH Palembang
 The Lymphatic System
• The body has approximately 600 lymph nodes, but only those
in the submandibular, axillary or inguinal regions may
normally be palpable in healthy people.1 Lymphadenopathy
refers to nodes that are abnormal in either size, consistency
or number. There are various classifications of
lymphadenopathy, but a simple and clinically useful system is
to classify lymphadenopathy as "generalized" if lymph nodes
are enlarged in two or more noncontiguous areas or
"localized" if only one area is involved.
• Distinguishing between localized and
generalized lymphadenopathy is important in
formulating a differential diagnosis.
• In primary care patients with unexplained
lymphadenopathy, approximately 3/4 of
patients will present with localized
lymphadenopathy and 1/4 with generalized
lymphadenopathy.
Kelenjar getah bening leher

Bazemore AW. Physician 2002;66:2103-10

Kelenjar getah bening aksila

Bazemore AW. Physician 2002;66:2103-10

Kelenjar getah bening inguinal

Bazemore AW. Physician 2002;66:2103-10

Level kelenjar getah bening leher

Level 1 : submental dan

submandibular
Level 2 : upper jugular
Level 3 : middle jugular
Level 4 : lower jugular
Level 5 : posterior
triangle group
Level 6 : anterior triangle
group

Robbins KT. Arch Otolaryngol Head Neck Surg. 2002;128:751-8

Pendekatan diagnosis
limfadenopati

• Definisi
• Klasifikasi
• Etiologi
• Pendekatan diagnosis
Definisi

Limfadenopati
Pembesaran kelenjar getah bening dengan ukuran lebih
besar dari 1 cm.
Ferrer R. Am Fam Physician 1998;58:1315
atau
Abnormalitas ukuran atau karakter kelenjar getah bening
Bazemore AW. Physician 2002;66:2103-10

Limfadenitis
Radang pada kelenjar getah bening yang disertai dengan
tanda-tanda inflamasi.
Elizabeth Partridge,
http://emedicine.medscape.com/article/960858-overview
Klasifikasi

Limfadenopati Limfadenopati
lokalisata generalisata

• Limfadenopati • limfadenopati
pada 1 regio pada 2 atau lebih
regio anatomi
yang berbeda

Bazemore AW. Physician 2002;66:2103-10

 Malignancies Etiologi

Infections

Autoimmune

Miscellaneous and
unusual condition
MIAMI
Bazemore AW. Physician 2002;66:2103-10
Iatrogenic
Etiologi : Malignancies

• Lekemia
• Limfoma
• Neoplasma kulit
• Kaposi sarkoma
• Metastase

Bazemore AW. Physician 2002;66:2103-10

Etiologi : Infectious
• Brucellosis
• Cat-scratch disease
• CMV
• HIV, infeksi primer
• Limfogranuloma venerium
• Mononukleosis
• Faringitis
• Rubela
• Tuberkulosis
• Tularemia
• Demam tifoid
• Sifilis
• Hepatitis virus
Bazemore AW. Physician 2002;66:2103-10
Etiologi : Autoimun

• Lupus eritematosis sistemik

• Artritis rematoid
• Dermatomiositis
• Sindroma Sjogren

Bazemore AW. Physician 2002;66:2103-10

Etiologi :Miscellaneous/unusual

• Penyakit Kawasaki
• Sarkoidosis

Bazemore AW. Physician 2002;66:2103-10

Etiologi : SHAK

H
S Hipertiroidisme
Sarcoidosis Histiositosis
Silicosis Hipertrigliseridemia
Storage disease

A K
Angiofolikular Kawasaki
hiperplasia Kikuchi
Angioimunoblastik Kimura

Bazemore AW. Physician 2002;66:2103-10

Etiologi : Iatrogenic

• Serum sickness
• Obat –obatan :
Alopurinol Pirimidone
Atenolol Pirimetamine
Captopril Kuinidin
Carbamazepine Trimetoprim sulfametoksazole
Hydralazine Sulindac
Penisilin Fenitoin

Bazemore AW. Physician 2002;66:2103-10

Pendekatan diagnosis
limfadenopati

• Definisi
• Klasifikasi
• Etiologi
• Pendekatan diagnosis
Pendekatan diagnosis

• Anamnesa
– Umur penderita dan lamanya
limfadenopati
628 penderita, penyebab benign dan self
limiting :
– 79% penderita berusia kurang dari
30 tahun
– 59% penderita antara 31-50 tahun
– 39% penderita di atas 50 tahun.

Ferrer R. Am Fam Physician 1998;58:1315

Bazemore AW. Physician 2002;66:2103-10
.
Pendekatan diagnosis

• Anamnesa
–Umur penderita dan lamanya
limfadenopati :
• Risiko keganasan sebagai
penyebab limfadenopati :
usia 40 tahun atau lebih : 4%
usia di bawah 40 tahun : 0,4%.

Ferrer R. Am Fam Physician 1998;58:1315

Bazemore AW. Physician 2002;66:2103-10
 Pendekatan diagnosis

• Anamnesa
–Umur penderita dan lamanya
limfadenopati
limfadenopati yang berlangsung
kurang dari 2 minggu atau lebih dari 1
tahun tanpa progresivitas ukuran
mempunyai kemungkinan sangat kecil
disebabkan keganasan
Ferrer R. Am Fam Physician 1998;58:1315
Bazemore AW. Physician 2002;66:2103-10
Pendekatan diagnosis

• Anamnesa :

• Paparan
• Simptom yang menyertai
 History

• First, are there localizing symptoms or signs to suggest

infection or neoplasm in a specific site?
• Second, are there constitutional symptoms such as fever,
weight loss, fatigue or night sweats to suggest disorders such
as tuberculosis, lymphoma, collagen vascular diseases,
unrecognized infection or malignancy?
 History

• Third, are there epidemiologic clues such as occupational

exposures, recent travel or high-risk behaviors that suggest
specific disorders?
• Fourth, is the patient taking a medication that may cause
lymphadenopathy? Some medications are known to
specifically cause lymphadenopathy (e.g., phenytoin ), while
others, such as cephalosporins, penicillins or sulfonamides,
are more likely to cause a serum sickness-like syndrome with
fever, arthralgias and rash in addition to lymphadenopathy.
 Pendekatan diagnosis

• Pemeriksaan fisik
– Karakter dan ukuran kelenjar getah bening
• 213 penderita dewasa , dengan ukuran
kelenjar :
–di bawah 1 cm : tidak ada keganasan
–1-2,25 cm : keganasan : 8%
–di atas 2,25 cm : keganasan : 38 %

Ferrer R. Am Fam Physician 1998;58:1315

Bazemore AW. Physician 2002;66:2103-10
.
 Pendekatan diagnosis

• Pemeriksaan fisik
–Karakter dan ukuran kelenjar getah
bening :
ukuran kelenjar maksimum 2 cm dan 1,5
cm merupakan batas ukuran yang
memerlukan evaluasi lebih lanjut untuk
menentukan adanya keganasan dan
penyakit granulomatous

Ferrer R. Am Fam Physician 1998;58:1315

Bazemore AW. Physician 2002;66:2103-10
 Physical Examination
• Size.
• Pain/Tenderness :The presence or absence of tenderness does not reliably
differentiate benign from malignant nodes.
• Consistency: Stony-hard nodes are typically a sign of cancer, usually
metastatic. Very firm, rubbery nodes suggest lymphoma. Softer nodes are
the result of infections or inflammatory conditions. Suppurant nodes may
be fluctuant. The term "shotty" refers to small nodes that feel like
buckshot under the skin, as found in the cervical nodes of children with
viral illnesses.
 Physical Examination
• Matting : can be either benign (e.g.,
tuberculosis, sarcoidosis) or malignant (e.g.,
metastatic carcinoma or lymphomas
• Location : infectious mononucleosis causes
cervical adenopathy and a number of sexually
transmitted diseases are associated with
inguinal adenopathy
Pemeriksaan fisik

• Pemeriksaan fisik
–Lokasi limfadenopati :
• Limfadenopati daerah kepala dan
leher
• Limfadenopati epitrohlear
• limfadenopati aksila
• Limfadenopati supraklavikula
• Limfadenopati inguinal
• Limfadenopati generalisata
 Physical Examination
• Supraclavicular lymphadenopathy has the highest risk of malignancy,
estimated as 90 percent in patients older than 40 years and 25 percent in
those younger than age.
• Lymphadenopathy of the right supraclavicular node is associated with
cancer in the mediastinum, lungs or esophagus.
• The left supraclavicular (Virchow's) node receives lymphatic flow from the
thorax and abdomen, and may signal pathology in the testis, ovaries,
kidneys, pancreas, prostate, stomach or gallbladder. Although rarely
present
Algoritme evaluasi limfadenopati

Anamnesa, pemeriksaan fisik

Jinak, self Autoimun/ keganasan Tidak

limited infeksi diketahui

Bazemore AW. Physician 2002;66:2103-10

Algoritme evaluasi limfadenopati

Jinak, self limited Autoimun/ infeksi

Dapat diterapi ? positif Tes spesifik

ya negatif
tidak

Terapi Reassurance, Penyebab

penjelasan tidak
perjalanan diketahui
penyakit

Pemantauan Bazemore AW. Physician 2002;66:2103-10

Algoritme evaluasi limfadenopati

Sugestif Tidak diketahui SHAK ?

keganasan
Risiko
tinggi Risiko keganasan

Pemeriksaan Risiko rendah

sesuai indikasi

generalisata regional
Biopsi eksisi
Test hematologi, Observasi
PPD, HIV, 1 bulan
HbsAg, ANA

negatif positif negatif

menghilang
biopsi menetap
Tidak Terapi
diketahui negatif Pemantauan
Evaluation of Suggestive S & S Associated with Lymphadenopathy
Mononucleosis-type
syndromes
Epstein-Barr virus*
Toxoplasmosis*
Cytomegalovirus*
Initial stages of HIV
infection*
Cat-scratch disease
Pharyngitis due to group A
streptococcus,
gonococcus
Tuberculosis lymphadenitis*
Secondary syphilis*
Hepatitis B*
Fatigue, malaise, fever, atypical
lymphocytosis
Splenomegaly in 50% of patients
80 to 90% of patients are
asymptomatic
Often mild symptoms; patients may
have hepatitis
"Flu-like" illness, rash
Fever in one third of patients; cervical
or axillary nodes
Fever, pharyngeal exudates, cervical
nodes
Painless, matted cervical nodes
Rash
Fever, nausea, vomiting, icterus
Monospot, IgM EA or VCA
IgM toxoplasma antibody
IgM CMV antibody, viral
culture of urine or blood
HIV antibody
Usually clinical criteria; biopsy
if necessary
Throat culture on appropriate
medium
PPD, biopsy
RPR
Liver function tests, HBsAg
Lymphogranuloma venereum Tender, matted inguinal nodes Serology

Chancroid Painful ulcer, painful inguinal nodes Clinical criteria, culture

Lupus erythematosus* Arthritis, rash, serositis, renal, neurologic, hematologic Clinical criteria, antinuclear antibodies,
disorders complement levels

Rheumatoid arthritis* Arthritis Clinical criteria, rheumatoid factor

Lymphoma* Fever, night sweats, weight loss in 20 to 30% of patients Biopsy

Leukemia* Blood dyscrasias, bruising Blood smear, bone marrow

Serum sickness* Fever, malaise, arthralgia, urticaria; exposure to antisera Clinical criteria, complement assays
or medications

Sarcoidosis Hilar nodes, skin lesions, dyspnea Biopsy

Kawasaki disease* Fever, conjunctivitis, rash, mucous membrane lesions Clinical criteria
Less common causes of lymphadenopathy

Lyme disease* Rash, arthritis IgM serology

Measles* Fever, conjunctivitis, rash, cough Clinical criteria, serology

Rubella* Rash Clinical criteria, serology

Tularemiala* Fever, ulcer at inoculation site Blood culture, serology

Brucellosis* Fever, sweats, malaise Blood culture, serology

Plague Febrile, acutely ill with cluster of tender nodes Blood culture, serology

Typhoid fever* Fever, chills, headache, abdominal complaints Blood culture, serology

Still's disease* Fever, rash, arthritis Clinical criteria, antinuclear antibody,

rheumatoid factor

Dermatomyositis* Proximal weakness, skin changes Muscle enzymes, EMG, muscle biopsy

Amyloidosis* Fatigue, weight loss Biopsy

*--Causes of generalized lymphadenopathy.

EA=early antibody; VCA=viral capsid antigen; CMV=cytomegalovirus; HIV=human immunodeficiency virus; PPD=purified protein derivative; RPR=rapid plasma reagin; HBsAg=hepatitis B
surface antigen; EMG=electromyelography.
 Unexplained Lymphadenopathy
Generalized Lymphadenopathy
• almost always indicates a systemic disease is present,
proceed with specific testing as indicated.
• If a diagnosis cannot be made, the clinician should obtain a
biopsy of the node.
• The diagnostic yield of the biopsy can be maximized by
obtaining an excisional biopsy of the largest and most
abnormal node
• The physician should not select inguinal and axillary nodes for
biopsy, since they frequently show only reactive hyperplasia
 Unexplained Lymphadenopathy
Localized Lymphadenopathy

 The decision about when to biopsy is more difficult.

 Patients with a benign clinical history, an unremarkable physical
examination and no constitutional symptoms should be reexamined in
three to four weeks to see if the lymph nodes have regressed or
disappeared.
 Patients with unexplained localized lymphadenopathy who have
constitutional symptoms or signs, risk factors for malignancy or
lymphadenopathy that persists for three to four weeks should undergo a
biopsy.
 Unexplained Lymphadenopathy
Localized Lymphadenopathy
 Biopsy should be avoided in patients with
probable viral illness because lymph node
pathology in these patients may sometimes
simulate lymphoma and lead to a false-
positive diagnosis of malignancy.
Take home message

• Limfadenopati merupakan
pembesaran kelenjar getah bening
dengan ukuran lebih besar dari 1 cm
• Etiologi : MIAMI :
malignant
infectious
autoimmune

miscellaneous/unusual
iatrogenic
Take home message

Lokasi Karakteristik
Usia
kelenjar kelenjar

Lamanya
limfadenopati Gejala lain

Etiologi
limfadenopati
 Take home message
• Lokasi kelenjar getah bening leher
dapat dibagi dalam 6 level untuk
memperkirakan sumber keganasan
primer yang bermetastase
• Level 1 : submental dan
submandibular
• Level 2 : upper jugular
• Level 3 : middle jugular
• Level 4 : lower jugular
• Level 5 : posterior triangle group
• Level 6 : anterior triangle group
Take home message

• Biopsi eksisi merupakan prosedur

diagnostik terpilih bila didapatkan
kecurigaan adanya keganasan.