Sandbox: Lymphadenopathy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Synonyms and keywords: Lymph nodes enlarged; Enlarged lymph nodes; Lymphadenitis; Swollen lymph nodes; Swollen/enlarged lymph nodes

Overview

Classification

  • Lymphadenopathy may be classified according to distribution into 2 groups:
  • Generalized lymphadenopathy
  • Localized lymphadenopathy

Pathophysiology

  • 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.
  • The inmune response between the antigen and lymphocyte that leads to cellular proliferation and enlargement of the lymph nodes.
  • Lymph nodes may also be enlarged secondarily as a result of the activation and proliferation of antigen-specific T and B cells (clonal expansion).
  • On gross pathology, characteristic findings of lymphadenopathy, include:
  • Enlarged lymph node
  • Soft greasy yellow areas within capsule
  • On microscopic histopathological analysis, characteristic findings of lymphadenopathy will depend on the aetiology.
  • Common findings, include:

Non-specific reactive follicular hyperplasia (NSRFH)

  • Large spaced cortical follicles
  • Tingible body macrophages, normal dark/light GC pattern

Lymph node metastasis

  • Foreign cell population (usually in subcapsular sinuses)
  • +/-nuclear atypia
  • +/-malignant architecture

Toxoplasmosis

  • Large follicles
  • Epithelioid cells perifollicular & intrafollicular
  • Reactive GCs
  • Monocytoid cell clusters

Cat-scratch disease

  • PMNs in necrotic area
  • "Stellate" (or serpentine) shaped micro-abscesses
  • Presence of granulomas

Dermatopathic lymphadenopathy

  • Melanin-laden histiocytes
  • Histiocytosis

Systemic lupus erythematosus lymphadenopathy

  • Blue hematoxylin bodies
  • Necrosis
  • No PMNs

Causes

  • Common causes of lymphadenopathy, include:
  • Infections (acute suppurative)
  • Fungal
  • Mycobacterial
  • Viral
  • Protozoal (e.g. toxoplasma)
  • Bacterial (e.g. chlamydia, rickettsia, bartonella)
  • Reactive
  • Follicular hyperplasia
  • Paracortical hyperplasia
  • Sinus histiocytosis
  • Granulomatous
  • Neoplastic
  • Drugs (e.g. cyclosporin, phenytoin, methotrexate)
  • Lipid storage diseases
  • IgG4-related sclerosing disease

Epidemiology and Demographics

  • Lymphadenopathy is very common.
  • The prevalence of lymphadenopathy is approximately [number or range] per 100,000 individuals worldwide.
  • The estimated incidence of lymphadenopathy among children in the United States ranges from 35%- 45%.

Age

  • Patients of all age groups may develop lymphadenopathy.
  • Lymphadenopathy is more commonly observed among children.

Gender

  • Lymphadenopathy affects men and women equally.

Race

  • There is no racial predilection for lymphadenopathy.

Risk Factors

  • The most common risk factors in the development of lymphadenopathy, include:
  • Local soft-tissue infections
  • Upper respiratory tract infection
  • Foreign travel

Natural History, Complications and Prognosis

  • Patients with lymphadenopathy may be symptomatic or asymptomatic, depending on the aetiology.
  • Early clinical features include palpable tenderness, pain, and fever.
  • Common complications of lymphadenopathy, include:

Mediastinal lymphadenopathy

Abdominal lymphadenopathy

Superficial lymphadenopathy

Prognosis will depend on the aetiology of the underlying disease.

Diagnosis

Diagnostic Criteria

Malignant Lymphadenopathy

  • Node > 2 cm
  • Node that is draining, hard, or fixed to underlying tissue
  • Atypical location (e.g. supraclavicular node)
  • Risk factors (e.g. HIV or TB)
  • Fever and/or weight loss
  • Splenomegaly

Benign Lymphadenopathy

  • Node < 1 cm
  • Node that is mobile, soft-or tender, and is not fixed to underlying tissue
  • Common location (e.g. supraclavicular node)
  • No associated risk factors
  • Palpable and painful enlargement

Symptoms

  • Symptoms of lymphadenopathy may include the following:
  • Constitutional symptoms
  • Fever
  • Weight loss
  • Fatigue
  • Night sweats
  • A directed history should be obtained to ascertain:
  • Use of drugs causing lymphadenopathy
  • Travel to endemic areas
  • Occupational risk (e.g. Fishermen, slaughterhouse workers, hunters, trappers)
  • High risk behavior or high risk sexual behaviors (e.g. I.V drug abuse, multiple partners)

Physical Examination

  • Patients with lymphadenopathy may have a pale or normal appearance.
  • Physical examination may be remarkable for:

Vitals

  • Temperature
  • High grade fever
  • Low grade fever
  • Pulse
  • Rapid (e.g. acute infections)

Skin

  • Rash may be present
  • Color change (indicative of inflammation)
  • Skin fistula draining pus may be present
  • Ulcers

Head

Palpating Anterior Cervical Lymph Nodes

Lymph nodes should be examined in the following order:

  • Anterior Cervical
  • Posterior Cervical
  • Tonsillar
  • Sub-Mandibular
  • Sub-Mental
  • Supra-clavicular

Characteristics to be noted while palpating lymph nodes:

  • Size
  • Pain/ tenderness
  • Increased tenderness (e.g infected lymph nodes)
  • Consistency
  • Matting

Gallery

Laboratory Findings

  • Laboratory findings consistent with the diagnosis of lymphadenopathy, include:

Complete Blood Count

Imaging Findings

Ultrasonography

  • On ultrasound, characteristic findings of lymphadenopathy, include:
  • Extent of lymph node involvement

CT

  • On CT, characteristic findings of lymphadenopathy, include:
  • Most nodes: 10 mm in short-axis
  • Sub-mental and sub-mandibular: 15 mm
  • Retropharyngeal: 8 mm

MRI

  • On MRI, characteristic findings of lymphadenopathy, include:

Treatment

  • There is no treatment for lymphadenopathy; the mainstay of therapy is treating the underlying condition.

References