Lymphadenopathy
Definition: lymph node enlargement
Signs/Symptoms:
Patient may complain of swollen glands or mass. Systemic illness with enlarged lymph nodes can have a variety of constitutional symptoms such as weight loss, fevers, nightsweats, fatigue and malaise.
Physical Exam:
The major lymph nodes to inspect and palpate include cervical nodes, axillary nodes (enlarged in breast cancer), epitrochlear nodes (enlarged in syphillus), and inguinal nodes. Always try to measure the size of the lymph node in centimeters. Take note if the enlarge lymph node is unilateral or bilateral, tender or nontender, whether it is mobile and whether it is erythematous. Lymph nodes from infection can be unilateral or bilateral and are usually mildly tender and mobile. Lymph node enlargement from malignancy can be nontender and fixed. Note whether lymphadenopathy is generalized or localized. Also ask the patient the duration of time the lymph nodes have been enlarged.
Etiology:
Viral:
-EBV, CMV, HSV, VSV, hepatitis, measles
-HIV: usually see generalized or local lymph node enlargement when patient is symptomatic from HIV itself. Enlarged lymph nodes can also be a sign of HIV related illness such as tuberculosis, histoplasmosis, CMV infection, Kaposi’s sarcoma, lymphoma, dermatological conditions such as seborrhoeic dermatitis. Persisent generalized lymphadenopathy is common in HIV positive patients and is often due to HIV alone. This illness is defined as follow: 1) more than 3 separate lymph node groups affected 2) at least 2 nodes > 1.5 cm in diameter at each site, 3) duration > 1 month 4) no local or contiguous infection that might explain the lymphadenopathy is found 5) exclude treatable causes such as syphilis and tuberculosis
Bacterial:
-generalized lymphadenopathy (tuberculosis, atypical mycobacteria, leptospirosis)
-localized lymphadenopathy (streptococci, tularemia, staphylococci)
Fungal and parasitic:
-Malaria (more rare in malaria), Toxoplasmosis, histoplasmosis
Immunologic:
-drug hypersensitivity (phenytoin), serum sickness, collagen vascular disease
Neoplasm:
-lymphoma, leukemia, metastatic carcinoma
Evaluation:
The lymph node enlargement is usually a cause of another overlying illness. It is important to guide your evaluation based on the patient’s history and physical exam and most likely diagnosis. To start, you can order a FBP (can check for blood disorders), chest xray (look for signs of tuberculosis) and rapid test, malaria blood smear. You can also guide your bloodwork based on physical exam, such as, if patient complains of abdominal pain and distention -> order abdominal ultrasound and liver function tests also.
Lymph node biopsy is also another method of diagnosis if the cause is still in question, can be useful in cases of malignancy.
***If a node is rapidly enlarging or there is nodal asymmetry and systemic complaints not otherwise explained-> the lymph node should be biopsied to exclude Kaposi’s sarcoma, lymphoma, infiltrative tuberculosis or fungal disease
Treatment:
Treatment is guided by underlying diagnosis that is causing lymphadenopathy.
Lymphadenopathy Clinical Cases
Case 1
30 year old male with history of HIV (CD4 count 200) presents to the hospital with complaints of large mass on the left side of his neck. He tells you that the mass has been present for 3 months and it has become twice the size in the past week. There is no pain associated with the mass and no exudate from the mass. He does complain of general body weakness and fevers for past 3 months. No cough, shortness of breath or chest pain.
On exam, the blood pressure is 100/70 and heart rate is 80. He is afebrile. Your neck exam reveals a 3 cm left sided anterior cervical lymph node which is mildly tender on palpation and freely mobile. There is no erythema or floccuence to the lymph node. The pulmonary and cardiac exam is normal and you do not feel any more enlarged lymph nodes in epitrocheal, axillary or inguinal regions.
- What is your differential diagnosis for the lymphadenopathy?
- Enlarged lymph nodes can also be a sign of HIV related illness such as tuberculosis, histoplasmosis, CMV infection, Kaposi’s sarcoma, lymphoma, dermatological conditions such as seborrhoeic dermatitis.
- Given that this node is solitary, KS, fungus, tb move to the highest points in the differential
- What lab tests or imaging studies do you want to order and why?
- FBP, CXR, LN Bx
You order a chest xray which comes back clear with no signs of pleural effusion or infilrates. Your FBP shows you that his WBC is very low and his hemoglobin and platelets are also very low.
- Does your differential diagnosis change with these results?
- Concerning for intra-marrow process; while HIV can do this, hematologic malignancies are also concerning, and other marrow infiltrative processes.
- Do you want to perform any other tests to help you make the diagnosis?
- BX the node!!
- Can you treat the patient at this point? How will you guide your treatment?
- ARV therapy can be initiated if it hasn’t yet. Otherwise, therapy is guided by the underlying etiology of the lymphadenopathy.
