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| | [[File:ImageLymphadenopathy.jpg|300px|thumb|right|Lymphadenopathy]] |
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| __NOTOC__ | | __NOTOC__ |
| {{SI}} | | {{Lymphadenopathy}} |
| {{CMG}} {{AE}} {{MV}} {{RT}} | | {{CMG}},{{shyam}};{{AE}} {{ADS}}, {{RT}} [[Ogechukwu Hannah Nnabude, MD]] |
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| {{SK}} Lymph nodes enlarged; Enlarged lymph nodes; Lymphadenitis; Swollen lymph nodes; Swollen/enlarged lymph nodes
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| ==Overview==
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| '''Lymphadenopathy''' (also known as "enlarged lymph nodes) refers to [[lymph nodes]] which are abnormal in size, number or consistency. Common causes of lymphadenopathy are [[infection]], [[autoimmune]] disease, or [[malignancy]].<ref name="!">{{cite journal|last=King|first=D|last2=Ramachandra|first2=J|last3=Yeomanson|first3=D|title=Lymphadenopathy in children: refer or reassure?|journal=Archives of Disease in Childhood: Education and Practice Edition|date=2 January 2014|pmid=24385291|doi=10.1136/archdischild-2013-304443|volume=99|pages=101–110}}</ref> Lymphadenopathy may be classified according to distribution into 2 groups: generalized lymphadenopathy and localized lymphadenopathy. The pathogenesis of lymphadenopathy is characterized by the inflammation of lymph nodes. This process is primarily due to an elevated rate of trafficking of [[lymphocytes]] into the node from the blood, exceeding the rate of outflow from the node. Lymph nodes may also be enlarged secondarily as a result of the activation and proliferation of antigen-specific T and [[B cells]] (clonal expansion). Lymphadenopathy is very common, the estimated incidence of lymphadenopathy among children in the United States ranges from 35%- 45%.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref> Patients of all age groups may develop lymphadenopathy. Lymphadenopathy is more commonly observed among children. Common complications of lymphadenopathy, may include: [[Abscess|abscess formation]], [[superior vena cava syndrome]], and [[intestinal obstruction]]. Diagnostic criteria for malignant lymphadenopathy, may include: node > 2 cm, node that is draining, hard, or fixed to underlying tissue, atypical location (e.g. supraclavicular node), associated risk factors (e.g. [[HIV AIDS|HIV]] or [[Tuberculosis|TB]]), fever and/or weight loss, and splenomegaly. On the other hand, diagnostic criteria for benign lymphadenopathy, may include: node < 1 cm, node that is mobile, soft-or tender, and is not fixed to underlying tissue, typical location (e.g. supraclavicular node), no associated risk factors, and palpable and painful enlargement. Laboratory findings consistent with the diagnosis of lymphadenopathy, may include: elevated lactate dehydrogenase (LDH), mild neutropenia, and [[leukocytosis]]. There is no treatment for lymphadenopathy; the mainstay of therapy is treating the underlying condition.<ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| ==Classification==
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| *Lymphadenopathy may be classified according to distribution into 2 groups:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| :*Generalized lymphadenopathy
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| :*Localized lymphadenopathy
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| ==Pathophysiology==
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| *The pathogenesis of lymphadenopathy is characterized by the inflammation of lymph nodes. This process is primarily due to an elevated rate of trafficking of lymphocytes into the node from the blood, exceeding the rate of outflow from the node.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
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| *The inmune response between the antigen and lymphocyte that leads to cellular proliferation and enlargement of the lymph nodes.
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| *Lymph nodes may also be enlarged secondarily as a result of the activation and proliferation of antigen-specific T and B cells (clonal expansion).
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| *On gross pathology, characteristic findings of lymphadenopathy, include:
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| :*Enlarged lymph node
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| :*Soft greasy yellow areas within capsule
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| *On microscopic histopathological analysis, characteristic findings of lymphadenopathy will depend on the aetiology.
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| *Common findings, include:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| '''Non-specific reactive follicular hyperplasia (NSRFH)'''
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| :*Large spaced cortical follicles
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| :*Tingible body macrophages, normal dark/light GC pattern
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| '''Lymph node metastasis'''
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| :*Foreign cell population (usually in subcapsular sinuses)
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| :*+/-nuclear atypia
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| :* +/-malignant architecture
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| '''Toxoplasmosis'''
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| :*Large follicles
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| :*Epithelioid cells perifollicular & intrafollicular
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| :*Reactive GCs
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| :*Monocytoid cell clusters
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| '''Cat-scratch disease'''
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| :*PMNs in necrotic area
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| :*"Stellate" (or serpentine) shaped micro-abscesses
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| :*Presence of granulomas
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| '''Dermatopathic lymphadenopathy'''
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| :*Melanin-laden histiocytes
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| :*Histiocytosis
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| '''Systemic lupus erythematosus lymphadenopathy'''
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| :*Blue hematoxylin bodies
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| :*Necrosis
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| :*No PMNs
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| ==Causes==
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| *Common causes of lymphadenopathy, include:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| :*'''Infections''' (acute suppurative)
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| ::*Fungal
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| ::*Mycobacterial
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| ::*Viral
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| ::*Protozoal (e.g. [[Toxoplasmosis|toxoplasma]])
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| ::*Bacterial (e.g. [[chlamydia]], [[Rickettsia rickettsii infection|rickettsia]], [[bartonella]])
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| :*'''Reactive'''
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| ::*Follicular hyperplasia
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| ::*Paracortical hyperplasia
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| ::*Sinus histiocytosis
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| ::*Granulomatous
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| ::*Neoplastic
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| ::*Drugs (e.g. cyclosporin, phenytoin, methotrexate)
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| ::*Lipid storage diseases
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| ::*IgG4-related sclerosing disease
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| ==Epidemiology and Demographics==
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| * Lymphadenopathy is very common.
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| *The estimated incidence of lymphadenopathy among children in the United States ranges from 35%- 45%.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| ===Age===
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| *Patients of all age groups may develop lymphadenopathy.
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| *Lymphadenopathy is more commonly observed among children.
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| ===Gender===
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| *Lymphadenopathy affects men and women equally.
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| ===Race===
| | {{SK}} Lymph nodes enlarged; Enlarged lymph nodes; Lymphadenitis; Swollen lymph nodes; Swollen/enlarged lymph nodes<br> |
| *There is no racial predilection for lymphadenopathy.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
| | '''For patient information, click [[Xyz (patient information)|here]]''' |
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| | ==Overview== |
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| ==Risk Factors== | | ==[[Lymphadenopathy classification|Classification]]== |
| *The most common risk factors in the development of lymphadenopathy, include:
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| :*Local soft-tissue infections
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| :*[[Upper respiratory tract infection]]
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| :*Foreign travel
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| == Natural History, Complications and Prognosis== | | ==[[Lymphadenopathy pathophysiology|Pathophysiology]]== |
| *Patients with lymphadenopathy may be symptomatic or asymptomatic, depending on the aetiology.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
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| *Early clinical features include palpable tenderness, pain, and fever.<ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| *Common complications of lymphadenopathy, include:<ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
| | ==Histopathology== |
| '''Mediastinal lymphadenopathy'''
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| * [[Superior vena cava syndrome]]
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| ** Tracheal and bronchial obstruction
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| ** [[Dysphagia]]
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| ** [[Hemoptysis]]
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| * [[Uric acid nephropathy]]
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| * [[Hyperkalemia]]
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| * [[Hypercalcemia]]
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| * [[Hypocalcemia]]
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| * [[Hyperphosphatemia]]
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| * [[Renal failure]]
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| '''Abdominal lymphadenopathy'''
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| * [[Intestinal obstruction]]
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| '''Superficial lymphadenopathy'''
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| * [[Abscess]] formation
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| * [[Cellulitis]]
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| * [[Fistulas]] (seen in lymphadenitis that is due to [[tuberculosis]])
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| * [[Sepsis]]
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| *Prognosis will depend on the aetiology of the underlying disease.
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| == Diagnosis == | | ==Causes== |
| ===Diagnostic Criteria===
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| ====Malignant Lymphadenopathy====
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| :*Node > 2 cm
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| :*Node that is draining, hard, or fixed to underlying tissue
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| :*Atypical location (e.g. supraclavicular node)
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| :*Risk factors (e.g. [[HIV AIDS|HIV]] or [[TB]])
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| :*Fever and/or weight loss
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| :*[[Splenomegaly]]
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| ====Benign Lymphadenopathy====
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| :*Node < 1 cm
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| :*Node that is mobile, soft-or tender, and is not fixed to underlying tissue
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| :*Common location (e.g. supraclavicular node)
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| :*No associated risk factors
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| :*Palpable and painful enlargement
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| === Symptoms ===
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| *Symptoms of lymphadenopathy may include the following:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| :*'''Constitutional symptoms'''
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| ::*[[Fever]]
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| ::*[[Weight loss]]
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| ::*[[Fatigue]]
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| ::*[[Night sweats]]
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| :* [[Malaise]]
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| :* [[Nausea]] and [[vomiting]]
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| :* [[Cachexia]]
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| *A directed history should be obtained to ascertain:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| :*Use of drugs causing lymphadenopathy
| | ==[[Lymphadenopathy differential diagnosis|Differentiating Lymphadenopathy from other Diseases]]== |
| :*Travel to endemic areas
| | ==[[Epidemiology and Demographics]]== |
| :*Occupational risk (e.g. Fishermen, slaughterhouse workers, hunters, trappers)
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| :*High risk behavior or high risk sexual behaviors (e.g. I.V drug abuse, multiple partners)
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| === Physical Examination === | | ==Laboratory Evaluation of Lymphadenopathy== |
| *Patients with lymphadenopathy may have a pale or normal appearance.
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| *Physical examination may be remarkable for:
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| ===Vitals===
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| * Temperature
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| :*High grade fever
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| :*Low grade fever
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| * Pulse
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| :*Rapid (e.g. acute infections)
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| ===Skin===
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| * [[Rash]] may be present
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| * Color change (indicative of inflammation)
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| * Skin [[fistula]] draining pus may be present
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| * Ulcers
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| ===Head=== | | ==Diagnostic Radiological Testing== |
| ====Palpating Anterior Cervical Lymph Nodes====
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| Lymph nodes should be examined in the following order:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| *Anterior Cervical
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| *Posterior Cervical
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| * Tonsillar
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| * Sub-Mandibular
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| *Sub-Mental
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| * Supra-clavicular
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| Characteristics to be noted while palpating lymph nodes:<ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
| | ==Treatment== |
| * Size
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| * Pain/ tenderness
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| :*Increased tenderness (e.g infected lymph nodes)
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| * Consistency
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| * Matting
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| ====Gallery====
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:head_scc1.jpg|'''Cervical adenopathy''': massive right side cervical adenopathy and facial asymmetry due to metastatic, intraoral squamous cell cancer. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
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| Image:head_scc2.jpg|'''Cervical adenopathy''': massive right side cervical adenopathy and facial asymmetry due to metastatic, intraoral squamous cell cancer. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
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| Image:head_cervical_ln.jpg|'''Cervical adenopathy''': large right anterior cervical lymph node. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
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| Image: Lymphadenopathy 001.jpg| '''Cervical lymphadenopathy'''. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
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| Image:head_cneck_adenop1.jpg|'''Cervical Adenopathy''': multiple right sided cervical lymph nodes. Images Courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA.
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| </gallery>
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| </div>
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| === Laboratory Findings ===
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| *Laboratory findings consistent with the diagnosis of lymphadenopathy, may include:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| '''Complete Blood Count'''
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| :*Elevated lactate dehydrogenase (LDH)
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| :*Mild neutropenia
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| :*Leukocytosis
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| :*Elevated markers of inflammation and acute phase reactants (e.g. ESR, C-reactive protein, ferritin)
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| ===Imaging Findings===
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| '''Ultrasonography'''
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| *On ultrasound, characteristic findings of lymphadenopathy, include:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="radio">Lymph node enlargment. Radiopedia. http://radiopaedia.org/articles/lymph-node-enlargement Accessed on May 9, 2016 </ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| :*Increased lymph node size.
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| '''CT'''
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| *On CT, characteristic findings of lymphadenopathy, include:<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref><ref name="radio">Lymph node enlargment. Radiopedia. http://radiopaedia.org/articles/lymph-node-enlargement Accessed on May 9, 2016 </ref><ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| :*Most nodes: 10 mm in short-axis
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| :*Sub-mental and sub-mandibular: 15 mm
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| :*Retropharyngeal: 8 mm
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| :*Loss of fatty hilum
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| :*Focal necrosis
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| :*Cystic necrotic nodes
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| :*Long-to-short axis ratio (>2cm - usually benign)
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| *The upper limit in size of a normal node varies with location.
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| == Treatment ==
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| *There is no treatment for lymphadenopathy; the mainstay of therapy is treating the underlying condition.<ref name="pmid24753638">{{cite journal |vauthors=Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A |title=Peripheral lymphadenopathy: approach and diagnostic tools |journal=Iran J Med Sci |volume=39 |issue=2 Suppl |pages=158–70 |year=2014 |pmid=24753638 |pmc=3993046 |doi= |url=}}</ref>
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| *For instance, infectious lymphadenopathy responds well to prompt treatment with antibiotics, and usually leads to a complete recovery. However, it may take months, for swelling to disappear. The amount of time to recovery depends on the cause.<ref name="AA">Lymph node enlargment. Wikipedia. https://en.wikipedia.org/wiki/Lymph_node Accessed on May 9, 2016</ref>
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| ==References== | | ==References== |
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