Lymphadenopathy

222 Lymphadenopathy



Instruction


Perform a general examination.


Examine this patient’s neck.



Salient features



History and examination


Use the mnemonic ALL AGES to approach a patient with lymphadenopathy:



ALL:


Age at presentation (e.g. infectious mononucleosis is commoner in younger age groups, Hodgkin’s disease has a bimodal peak)

Location(s) of enlarged lymph nodes: those outside the inguinal regions, enlarged for >4 weeks and measuring 1 cm2 or larger without an obvious diagnosis should be considered for biopsy (Semin Oncol 1993;20:570–82)

Length of time the lymph nodes are present.

AGES:


Associated symptoms and signs including fever (‘B’ symptoms: temperature >38°C, drenching night sweats, unexplained weight loss >10% body weight)

Generalized lymph node enlargement

Extranodal organ involvement

Splenomegaly: consider infectious mononucleosis, lymphoma, chronic lymphocytic leukaemia, and acute leukaemia; rare in metastatic cancer (Cancer 1987;60:100–2).

• As soon as you feel a group of lymph nodes, examine drainage areas for obvious pathology. For example:


• Inguinal lymph nodes: examine the lower limbs and external genitalia

• Axillary lymph nodes: examine the chest, breasts and upper limbs

• Upper cervical lymph nodes: examine the chest, breast and upper limbs; also, perform an ear, nose and throat (ENT) examination for nasopharyngeal carcinoma

• Lower cervical and supraclavicular lymph nodes: examine the thyroid, chest, abdomen for gastric carcinoma (Virchow’s nodes) and testis.

• Examine other lymph node areas in a systemic manner: submental, submandibular, deep cervical (upper and lower), occipital, posterior triangle, supraclavicular, axillary, epitrochlear and inguinal.


• Examine the mouth for the following signs:


• Tonsillar lymph nodes

• Palatal petechiae and pharyngitis (glandular fever)

• Neoplastic tumours or ulcers.

• Examine the abdomen for liver and spleen.


• Examine the chest and do a chest radiography: for bronchogenic carcinoma, TB.



Diagnosis


This patient has generalized lymphadenopathy, probably a lymphoma— either Hodgkin’s or non-Hodgkin’s (aetiology)—and has severe disease, as evidenced by alopecia, presumably caused by chemotherapy (functional status). I would like to discuss other causes of generalized lymphadenopathy.



Questions




What are the causes of regional lymphadenopathy?




Cervical lymphadenopathy. Causes include infections and malignancies. Infectious causes include bacterial pharyngitis, dental abscess, otitis media, infectious mononucleosis, cytomegalovirus, gonococcal pharyngitis, toxoplasmosis, hepatitis and adenovirus. Malignancies include non-Hodgkin disease, Hodgkin disease and squamous cell carcinoma of head and neck.


Virchow node (anterior left supraclavicular lymph node; also known as Troiser’s ganglion). Enlargement suggests the presence of a thoracic or abdominal neoplasm (Am J Surg 1979;138:703). Common causes include carcinoma of breast, bronchus, lymphomas and GI neoplasms.


Delphian node (a midline prelaryngeal lymph node). Heralds thyroid disease, laryngeal malignancy or lymphoma.


Axillary lymphadenopathy. Causes include infections and malignancies. Infectious causes include staphylococcal, streptococcal infections of the arm, cat-scratch fever, tularaemia and sporotrichosis. Malignant causes, including Hodgkin’s disease, non-Hodgkin lymphoma, carcinoma of breast and melanoma, are common.


Epitrochlear lymphadenopathy. The most common causes are lymphoma/chronic lymphatic leukaemia and infectious mononucleosis. Other diagnoses include HIV, sarcoidosis and connective tissue disorders. In developing countries, secondary syphilis, lepromatous leprosy, leishmaniasis and rubella are important causes.


Inguinal lymphadenopathy. In adults, some degree of lymph node enlargement is not uncommon. In those who walk outdoors with footwear, benign reactive lymphadenopathy is common. Malignant causes include lymphoma, malignant melanoma, carcinoma of external genitalia. Benign causes include cellulitis, syphilis, chancroid, genital herpes and lymphogranuloma venereum.


Node of Cloquet (also known as Rosenmüller node). A deep inguinal lymph node located near the femoral canal. When palpable it may be mistaken for an inguinal hernia.



What are the causes of generalized lymphadenopathy?




• Lymphomas, chronic lymphatic leukaemia, acute lymphoblastic leukaemia


• Glandular fever, cytomegalovirus


• HIV infection, toxoplasmosis


• SLE, rheumatoid arthritis, sarcoid


• Chronic infections such as TB, secondary syphilis, brucellosis


• Drugs: phenytoin.


(Use the mnemonic CHICAGO: cancers, hypersensitivity, infections, connective tissue disorders, atypical lymphoproliferative disorders, granulomatous disorders, other unusual causes.)

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Dec 4, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Lymphadenopathy

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