Approach to

Lymphadenopath
y
Dr Putra Hendra SpPD
UNIBA

Definition

Approx 600 LN in
body
LAN = abnl size,
number, consistency
Generalized vs
Local
Peripheral (central
LAN presents
differently)

Lymph Nodes

Anatomy

Function

Collection of lymphoid cells attached to both vascular

and lymphatic systems
Over 600 lymph nodes in the body
To provide optimal sites for the concentration of free or
cell-associated antigens and recirculating lymphocytes
sensitization of the immune response
To allow contact between B-cells, T-cells and
macrophages

Lymphadenopathy - node greater than 1cm in size

Why do lymph nodes

enlarge?

Increase in the number of benign

lymphocytes and macrophages in response
to antigens
Infiltration of inflammatory cells in
infection (lymphadenitis)
In situ proliferation of malignant
lymphocytes or macrophages
Infiltration by metastatic malignant cells
Infiltration of lymph nodes by metabolite
laden macrophages (lipid storage diseases)

Definitions

Pathologic Lymph Node

Acute Lymphadenopathy

< 2 weeks duration

Subacute Lymphadenopathy

>2cm in children is considered abnormal

2-6 weeks duration

Chronic Lymphadenopathy

> 6 weeks duration

Epidemiology

0.6% annual incidence of

unexplained adenopathy in the
general population
10% were referred to a subspecialist
and 3.2 % required a biopsy and
1.1% had a malignancy

Epidemiology

Larsson et al. 38-45% of normal children

have palpable cervical lymphadenopathy
Park et al. 90% of children aged 4-8 have
lymphadenopathy
These masses can be mistaken for other local
and systemic processes

Congenital Masses
Malignancies
Local presentation of systemic disease

Found by parents and caregivers and

demand workup

Physical Exam

General
Febrile or toxic appearing
Skin
Cellulitis, impetigo, rash
HEENT
Otitis, pharyngitis, teeth, and nasal cavity
Neck
Size
Unilateral vs Bilateral
Tender vs Nontender
Mobile vs Fixed
Hard vs Soft
Lungs
Consolidations suggesting TB
Abdomen
Hepatosplenomegaly
Extremities
Inguinal and Axillary adenopathy

When to worry?

Age
Characteristics of the node
Location of the node
Clinical setting associated with
lymphadenopathy

Risk Factors to Keep in

Mind
Size Matters!!

Age Matters!!

In one series of 213 adults with unexplained

LAN who went on to biopsy
LN <1 cm - 0% malignancy
LN 1-1.5 cm - 8% malignancy
LN > 1.5x1.5 (2.25 cm2) - 38% malignancy
Age > 40, malignancy is more common
(Age >40 = 4% vs Age < 40 = 0.4%)

Location Matters!!

Supraclavicular has the highest risk of

Malignancy - est at 90% in patients >40 and
25% in ages < 40

Characteristics of the
node

Consistency Hard/Firm vs Soft/Shotty;

Fluctuant
Mobile vs Fixed/Matted
Tender vs Painless
Clearly demarcated
Size

When to worry 1.5-2cm in size

Epitroclear nodes over 0.5cm; Inguinal over
1.5cm

Duration and Rate of Growth

EXAMINATION OF A
LUMP
Size
Consistency: Hodgkins rubbery
Tuberculosis matted
Metastatic cancer craggy
Calcified stony hard
Tenderness: infectious
mononucleosis, dental sepsis, tonsilitis
Fixation: malignancy

Presentation of
lymphadenopathy

Unexplained
lymphadenopathy
3/4 presents with
localized
1/4 present with
generalized

Posterior Cervical LAN Mono

Mycobacterial Adenitis Scrofula

Lymphatic spread of M.
tuberculosis as well as atypical
mycobacteria (M. scrofulaceum,
MAI)

Mycobacterial
Lymphadenitis

TB abscess

as part of immune reconstitution syndrome

Diagnostic Tests

Fine needle aspiration biopsy

(FNAB)
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Ultrasonography
Radionucleotide scanning

Role of Ultrasound
(Ahuja et al. 2005)

No radiation exposure
Good for following the progress of an abscess
Differentiate Reactive vs Malignant nodes

Reactive

Malignant

<1 cm
Oval (S/L ratio <0.5cm)
Normal hilar vascularity
Low resistive index with high blood flow
>1 cm
Round (S/L ratio >0.5cm)
No echogenic hilus
Cogaulative necrosis present
High resistive index with low blood flow
Extracapsular spread

Sensitivity 95% and Specificity 83% for differentiating

reactive vs metastatic lymph nodes

Fine Needle Aspiration

Biopsy

Standard of diagnosis
Indications
Any neck mass that is not an obvious
abscess
Persistence after a 2 week course of
antibiotics

Small gauge needle

Reduces bleeding
Seeding of tumor not a concern

No contraindications (vascular ?)

Fine Needle Aspiration

Biopsy

Differential Diagnosis

Major Pathogens
HIV- related

persistent generalized lymphadenopathy (PGL)

Opportunistic infections
toxoplasmosis, infections with Nocardia
(histoplasmosis, penicilliosis,

tuberculous lymphadenitis, CMV,

species, fungal infections
cryptococcus, etc.)

Reactive Lymphadenopathy
pyomyositis, pyogenic skin
infections, ear, nose, and throat (ENT) infections
STIs
syphilis, inguinal lymphadenopathy due to donovanosis, chancroid
or lymphogranuloma venereum (LGV)
(see WHO or MSF guidelines)
Malignancies lymphoma, Kaposis sarcoma

Lymphadenitis

Very common, especially within 1st decade

Tender node with signs of systemic infection
Directed antibiotic therapy with follow-up
FNAB indications (pediatric)

Actively infectious condition with no response

Progressively enlarging
Solitary and asymmetric nodal mass
Supraclavicular mass (60% malignancy)
Persistent nodal mass without active infection

Generalized
Lymphadenopathy

Malignancy lymphoma, leukemia, Kaposis

sarcoma, metastases
Autoimmune SLE, RA, Sjogrens syndrome,
Stills disease, Dermatomyositis
Infectious Brucellosis, Cat-scratch disease,
CMV, HIV, EBV, Rubella, Tuberculosis,
Tularemia, Typhoid Fever, Syphilis, viral
hepatitis, Pharyngitis
Other Kawasakis disease, sarcoidosis,
amyloidosis, lipid storage diseases,
hyperthyroidism, necrotizing lymphadenitis,
histiocytosis X, Castlemens disease

Granulomatous
lymphadenitis

Typical M. tuberculosis
more common in adults
Posterior triangle nodes
Rarely seen in our population
Usually responds to anti-TB
medications
May require excisional biopsy for
further workup

Drug Induced
Lymphadenopathy

Medications

Phenytoin
Pyrimethamine
Allopurinol
Phenylbutazone
Isoniazide

Immunizations

Smallpox (historically)
Live attenuated MMR
DPT
Poliomyelitis
Typhoid fever

**Usually self limited and resolves with cessation of

medication or with time in the case of
immunization induced LAD

Inguinal LAN

STDs
Tinea infections (pedis/cruris)
Pelvic/Genital Malignancy
(squamous/melanoma)
Bubonic Plague? - was there an
exposure?
Lymphoma

Terima kasih

Questions?