Case scenario 1:

Durjoy 7 yrs old boy came with the complaints

of low grade intermittent fever for 2 and
half months, abdominal mass with right sided
jaw swelling for same duration. O/E, he is
mildly pale with normal vital parameters,
palpable right submandibular lymph node &
anterior cervical chain of both sides.
Distended abdomen with a mass involving left
lumber, left iliac and umblical region, firm in
consistency, with irregular margin and
surface and hepatomegaly.
Case scenario 2:
Munira 11 years old girl admitted
with the complaints of low grade
intermittent fever and non
productive cough for 3 months.
She had a H/O contact with TB
patient. O/E, she is afebrile,
moderately pale, normal vitals,
presence of BCG mark with
cervical lymphadenopathy which
is matted, firm and non tender.
SEMINAR
Approach to a Patient with
Lymphadenopathy

Presented By-

Dr. Nafisa Yesmin

Dr. Md. Tanvir Ahammed
(Phase A Resident, PHO)
 Learning Objectives
• Provide an approach to the patient with
lymphadenopathy.
• Be able to differentiate between benign and
serious illness.
• Knowledgeable of nodal distribution and
anatomic drainage.
• Present a substantial differential diagnosis.
• Indications for nodal biopsy.
 Definition:
Lymphadenopathy

• Lymph nodes that are abnormal

in size (more than 2.5 cm),
consistency or number.
Types:

- Generalized.
- Localized.
 Lymphatic System
• Network that filters antigens from
the interstitial fluid.

• Primary site of immune response from

tissue antigens.

• Lymphatic drainage in all organs of the

body except brain, eyes, marrow and
cartilage.
Lymphatic system: continued..

• Flaccid thin walled channels

progressive caliber.

• 600 lymph nodes in body.

• Slow flow, low pressure system returns

interstitial fluid to the blood system.
Secondary lymphoid tissue
 Lymph nodes
• Capsular shell
• Fibroblasts and
reticulin fibers
• Macrophages
• Dendritic cells
• T cells
• B cells
Draining area:
Location Lymphatic drainage
Submandibular Tongue, sbmaxillary gland, lips and mouth
conjunctiva.

Submental Lower lip, floor of mouth, tip of tongue, skin

of cheek.

Jugular Tongue, tonsil, pinna, parotids

Post Cervical Scalp and neck, skin of arm and pectorals,

thorax, cervical and axillary nodes.
Draining area: continued….

Location Lymphatic drainage

Suboccipital Scalp and head.

Postauricular External auditory meatus, pinna, scalp.

Preauricular Eyelid, conjunctiva, temporal region,

pinna.

Right supra Mediastinum, lungs, esophagus.

clavicular
Draining area: continued…

Location Lymphatic drainage

Left supraclavicular Thorax, abdomen via thorasic duct

Axillary Arm, thorasic wall, breast.

Epitrochlear Ulnar aspect of forearm and hand.

Inguinal Penis , scrotum, vulva, vagina,

perineum, gluteal region, lower
abdominal wall, lower anal canal.
Causes of Lymhadenopathy:

1. Non specific reactive hyperplasia (polyclonal).

2. Infection
A. Bacterial:
Staphylococcus, Streptococcus, anaerobes, Tuberculosis, Atypical
mycobacteria, bartonella henselae, brucellosis, salmonella typhi,
dipktheria, C. trachomatis ( lymphogranuloma venereum )
calymmatobacterium granulomatosis, francisella tularensis
B. Viral:
EBV, CMV, adeno virus, RSV, influenza, coxasackie virus, rubella,
rubeola, varicella, HIV, HSV type 2
C. Protozoal:
Toxoplasmosis, malaria, trypanosomiasis.
D. Fungal:
Coccidioidomycosis (valley fever), histoplasmosis, cryptococcus,
aspergillosis.
E. Post vaccination:
Small pox, live attenuated measles, DPT, salk vaccine, typhoid fever.
Causes of Lymhadenopathy: continued…

3. Connective tissue disorders:

A. Rheumatoid arthritis.
B. SLE

4. Hypersensitivity state:
A. Serum sickness.
B. Drug reaction (allopurinol, INH, anti leprosy, anti thyroid,
pyrimethamine, phenylbutazone, mephenytoin.)

5. Lympho-proliferative disorder:
A. Angioimmunoblastic lymphadenopathy with dysproteinemia.
B. X-linked Lympho-proliferative syndrome.
C. Lymphomatoid granulomatosis.
D. sinus histiocytosis with massive lymphadenopathy.
E. Castleman diseases.
F. Autoimmuno Lympho-proliferative syndrome.
G. Post transplant Lympho-proliferative disorder.
Causes of Lymhadenopathy: continued…

6. Neoplastic diseases:
A. Hodgkin & Non hodgkin lymphomas.
B. Leukemia.
C. Metastatic diseases from solid tumors ; Neuroblastoma, Naso
pharyngeal carcinoma, rhabdomyosarcoma, thyroid cancer
D. Histiocytosis.

7. Storage diseases:
A. Niemann pick diseases.
B. Gaucher diseases.
C. Cystinosis.

8. Immunodeficiency state:
A. Chronic granulomatous diseases.
B. Leukocyte adhesion deficiency.
C. Primary dysgammaglobinemia with lymphadenopathy.

9. Miscellaneous causes:
A. Kawasaki diseases.
B. Kikuchi fujimoto diseases.
C. Sarcoidosis.
Differential Diagnosis of Non Lymphnode
mass in neck:

1. Cystic hygroma.
2. Branchial cleft anomalies.
3. Branchial cyst.
4. Thyroglossal duct cyst.
5. Epidermoid cyst.
6. Lateral process of lower cervical
vertebrae may be misdiagnosed as
supraclavicular node.
Next Presenter
Diagnostic Approach to Lymphadenopathy:
History:

* Patient age:
<6yrs at head neck region- neuroblastoma, rhabdomyosarcoma,
leukemia, NHL
7-13yrs- NHL, HL, thyroid cancer, rhabdomyosarcoma.
>13yrs- HL

* Duration of lymphadenopathy
* Fever
* Recent respiratory tract infection
* Sore throat
* Localizing symptom in a specific site
* Constitutional symptoms (Fever, Weight loss, Night sweat)
* Occupational exposure ( recent travel
history, high risk behaviors)
* Contact history.
* Trauma or skin leison.
* Animal exposure: cat scratches, rodent
bite, tick bite.
* IV drug use.
* Recent history of blood transfusion or
transplant.
* Dietary history ( Toxoplasmosis).
* Medication.
Physical examination:
General:

-Appearance.
- Fever.
- Anaemia.
- Jaundice.
- Cyanosis.
- Clubbing.
- JVP
- Bony Tenderness
General Examination: continued…

- Skin lesions. (ulcer, bruising, urticaria,

BCG mark, soft tissue swelling)
- Pigmentation.
- Eye ( conjunctivitis)
- ENT (external auditory meatus, pinna)
- Oral cavity ( tongue, lips, mouth,
cheeks, tonsil).
- Pulse.
- Blood pressure.
General Examination: continued…

- Lymph node examination.

> Localized or generalized.

> Examine the region drained by the nodes.

- Size of nodes: >2.5cm.

- Consistency.
- Matting: TB, sarcoidosis, lymphogranuloma venerum.
- Presence or absence of nodal tenderness:
due to increase size, inflammatory process,
haemorrhage into the necrotic center
of a malignant node.
- Signs of inflammation over the node.
Systemic Examination:

** Respiratory system: RR, Dyspnea, Breath sound,

Added sound.

** GIT Examination: Hepato-Spleenomegaly.

** Genito-urinary system examination: External genitalia.

** Locomotor system examination: Feature of arthritis.

Investigation:
- CBC with PBF, ESR
- Blood culture
- Skin test for TB
- Bacteriologic culture of regional leison (eg. Throat )
- Chest x-ray & CT scan (if necessary)
- Abdominal sonogram & CT (If indicated)
- Lymph node aspiration & biopsy for Gram stain &
culture,
Histopathological study,
Immunohistochemical stain,
flowcytometry,
gene rearrangement study.
- Bone marrow examination.
Investigation: continued…

On special circumstances:
- LFT eg. HBV
- Renal function test. ( SLE)
- EKG & ECG (if kawasaki diseases is suspected)
- ANA
- RA
- Specific serologic test for EBV, bartonella
henselae, toxoplasmosis, CMV, HIV
- CSF study for malignant cell.
- PET scan.
Indication of Biopsy:

* If initial history and physical examinations

suggest malignancy.
* Lymphnode size is greater than 2.5cm, in
absence of signs of infection.
* Lymphnode persists or enlarge.
* Appropriate antibiotics fail to shrink node
within 2 weeks.
* Supraclavicular lymphadenopathy.
Precaution that should be observed
during biopsy:

* Upper cervical and inguinal area should be avoided.

* Largest node should be biopsied not the
most accesible one.
* Node should be removed intact.
Evaluation of Suspected Causes of Lymphadenopathy :
Disorder Associated finding Test/Investigation

Mononucleosis type Fatigue, malaise, fever,

syndromes- atypical lymphocytosis
EBV Spleenomegaly IgM VCA
Toxoplasmosis 90% patient asymptomatic. IgM toxoplasma antibody
CMV Often mild symptom, IgM CMV antibody, viral
patients may have culture of urine or blood.
hepatitis

Initial stage of HIV Flu like illness, rash HIV antibody

infection
Cat Scratch diseases Fever in one third of Usually clinical criteria,
patients, cervical or biopsy if needed.
axillary nodes.
Pharyngitis due to Fever, pharyngeal Throat culture
group A streptococcus, exudates, cervical nodes
gonoccus
 Disorder Associated finding Test/Investigation

Tuberculosis Painless matted cervical nodes PPD, biopsy

Secondary syphilis Rash RPR

Hepatitis B Fever, Nausea, vomiting, Icterus LFT, HBsAg

Lymphogranuloma Tender matted inguinal nodes Serology

Venerum

Chancroid Painful ulcer, painful inguinal nodes Clinical criteria,

culture

RA Arthritis Clinical criteria, RF

 Disorder Associated finding Test/Investigation

Leukemia Blood dyscrasias, bruising Blood smear, Bone

marrow

Lymphoma Fever, night sweats, weight loss Biopsy

Rhabdomyosarcoma Head and neck mass(40%) Biopsy

Histiocytosis Seborhheic eczema,painfull osteolytic FNAC and

bony lesion histopathology,bone
scan

Neuroblastoma Abdominal mass, hypertension, SVCS Biopsy

 Disorder Associated finding Test
SLE Arthritis, rash, serositis, renal, Clinical criteria,
neurologic, haematologic disorder ANA, Complement
level

Serum sickness Fever, malaise, arthralgia, Complement assay

urticaria, exposure to anti sera or
medication

Sarcoidosis Hilar node, Skin leison, dyspnea Biopsy

Kawasaki Fever, conjunctivitis, rash, Clinical criteria

diseases mucous membrane leison

Dermatomyositis Proximal weakness, skin changes Muscle enzyme,

EMG, muscle biopsy
Few Terms:

** Mononucleosis type syndrome:

Patient with these syndrome present with

lymphadenopathy, fatigue, malaise, fever and
increase atypical lymphocyte. Most commonly
due to EBV, CMV, toxoplasmosis, streptococcal
pharyngitis, HBV infection, HIV infection.
** Non specific reactive hyperplasia
(NSRH):

Non specific reactive hyperplasia of lymph

node represents body’s response to antigenic
stimuli (foreign material, cellular debris,
micro organism). NSRH accounted for 20%
patients of cervical lymphadenopathy. The
disease affected comparatively younger
people of both sexes equally. Routine
investigations offered little diagnostic help.
The disease resolve spontaneously in
1/3rd of patients, 1/4th developed
specific entities, while in the rest it
continued as a prolonged ailment.
Lymph node biopsy should be planned
meticulously to avoid missed diagnosis.
If the lymphadenopathy of NSRH does
not subside spontaneously within 2
months, a re-biopsy is advised to pick
up a specific ailment.
** Ulceroglandular syndrome:

This syndrome defined as presence of skin lesion

with associated regional lymphadenopathy. The
classic cause is tularemia, rabbit or tick bite,
streptococcal infection (impetigo), cat scratch
disease.

** Occuloglandular syndrome:

The syndrome involves the combination of

conjunctivitis and preauricular lymphadenopathy.
Common cause is keratoconjunctivitis and cat
scratch disease.
References:

1. Manual of Pediatric Haematology and

Oncology – Philip Lanzkowsky
2. Nelson Textbook of Pediatrics.
3. American Family Physician (
www.aafp.org)
4. Basic Histology .