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Lymphadenopathy and Lymphadenitis

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Presentation on theme: "Lymphadenopathy and Lymphadenitis"— Presentation transcript:

1 Lymphadenopathy and Lymphadenitis
Dr. Orli Megged SZMC

2 Objectives Etiologies of infectious lymphadenitis
Clinical presentation Differential diagnosis

3 Pathophysiology of Lymphadenopathy
Initial Infection URI / Pharyngitis / Otitis Media / Odontogenic infection Lymphatic drainage Presentation to T cells Proliferation of clonal cells Release of cytokines leading to chemotaxis Activation of B cells Immunoglobulin release Continued proliferation of immune response

4 Pathophysiology Cont’d
Results of the Immune Response Cellular Hyperplasia Leukocyte Infiltration Tissue Edema Vasodilation and Capillary Leak Tenderness due to capsule distension

5 DD Congenital Masses Malignancies
Local presentation of systemic disease Other

6 Differential Diagnosis Congenital Masses
Thyroglossal duct cyst Moves with tongue protrusion and is midline Dermoid Cyst Midline and often has calcifications on plain films Branchial Cleft Cyst Smooth and fluctuant along SCM border Laryngocele Enlarges with valsalva Hemangioma Mass is presents after birth, rapidly grows, plateaus, and is red or bluish in color Cystic Hygroma Transilluminates and is compressible Sternocleidomastoid Tumor Lymphadenopathy does not present with torticollis Cervical Ribs Bilateral, hard and immobile

7 Malignancies Lymphoma Leukemia Lung (mediastinal)
Hodgkin's lymphoma Non-Hodgkin's lymphoma Leukemia CLL Lung (mediastinal) Metastatic: breast, melanoma… (Usually axillary), SCC

8 Differential Diagnosis Systemic diseases
Viral - Most common form Often bilateral, diffuse, non-tender Other Signs/Symptoms are consistent with URI Mumps – parotis, not lymph node EBV, CMV Adenovirus Other

9 Differential Diagnosis Systemic diseases
Bartonella Toxoplasmosis STD’s Kawasaki disease

10 MUMPS Painful swelling, superior to jaw line Uni or bilateral Epidemic
Vaccinated? Look for orchitis Sometimes meningitis

11 Infectious Mononucleosis EBV, CMV
Fever Sore throat Hepatosplenomegaly Lymphocytosis

12 Cat Scratch Disease – Bartonella Henselae
Exposure to cat bite or scratch Can take up to 2 weeks to develop Tender. Fever & malaise are mild and present in <50% of patients Diagnosis: serology or PCR Treatment: none / antibiotics Antibiotics always given to immunocompromised patients to prevent disseminated disease **Other less common zoonotic causes are tularemia, brucellosis, and anthracosis.

13 Toxoplasmosis - Toxoplasma gondii
Mechanism Consumption of undercooked meat Ingestion of oocytes from cat feces Symptoms Malaise, fever, sore throat, myalgias 90% have cervical lymphadenitis Diagnosis: serology Treatment: none. In pregnancy, congenital, immunocompromised, retinitis: pyrimethamine sulfadiazine

14 STD’s Lymphogranuloma venereum Syphilis Granuloma inguinale HIV

15 Kawasaki Disease Diagnosis: Fever>5 days + 4/5:
Unilateral Cervical lymphadenopathy Edema of palms and soles Nonpurulent Conjunctivitis Strawberry Tongue Rash Complications Coronary artery aneurysms Treatment IVIG and Aspirin

16 Other Medications Immunizations Sarcoidosis Phenytoin, Allopurinol …..
Smallpox (historically) Live attenuated MMRV BCG Sarcoidosis


18 Suppurative Bacterial Lymphadenitis
Staphylococcus aureus and Group A Streptococcus Anaerobes Usually acute onset, fever, CBC Management: antibiotics (which one?) If not resolving or getting worse Ultrasound and/or CT with contrast to evaluate for phlegmon/abscess/infiltrate FNA vs Surgical I&D vs Surgical Excision if abscess is identified

19 Suppurative Lymphadenitis with Overlying cellulitis

20 Subacute Lymphadenitis
2-6 weeks Usually no improvement with antibiotics DD: Atypical Mycobacteria Cat Scratch disease Toxoplasmosis TB

21 Atypical Mycobacteria
Leading cause of sub-acute disease Species involved: Mycobacterium avium-intrucellulare Mycobacterium scrofulaceum Develops over weeks to months Lymph nodes may have violaceous skin over the node No fever, normal behavior, no pain Diagnosis: acid fast stain and culture, can take weeks. PCR. Treatment: surgical excision of involved lymph nodes, some offer antibiotics (Clarithromycin plus Rifabutin)

22 Atypical Mycobacteria Zeharia et al 2008
Retrospective review of 92 children with chronic non-TB mycobacterial cervical lymphadenitis Parents opted for conservative treatment and followed for at least 2 years. Outcomes Purulent drainage in 97%, for 3-8 weeks Total Resolution 6 months in 71% 9 months in 98% 12 months in 100% No complications other than a skin colored flat scar in the area of drainage at 2 year follow up

23 Atypical Mycobacteria Zeharia et al 2008
Conclusions Surgical Therapy Complication rates of 10-28% Large incision with poor cosmetic result Fistula formation and prolonged wound drainage Repeat surgical procedures for recurrence Transient or permanent facial nerve paralysis Expectant management is recommended

24 Tuberculosis lymphadenitis (Scrofula)
Presenting Signs and Symptoms Cervical nodes most commonly involved Firm, discrete nodes Fluctuant nodes Skin breakdown, abscesses, chronic sinuses healing and scarring

25 Tuberculosis (Scrofula)

26 Kikuchi-Fujimoto disease
Benign condition Associated Signs and Symptoms Fever Nausea Weight loss Night Sweats Arthralgias Hepatosplenomegaly Thought to have viral or autoimmune etiology The majority spontaneously regress within 6 months Lymphoma? Kikuchi !

27 Approach to lymphadenitis

28 History Fever, malaise, anorexia, myalgias Pain or tenderness of node
Sore Throat / URI / Toothache / Ear pain Insect Bites Exposure to animals History of travel or exposure to TB Immunizations Medications

29 Physical Exam General Skin ENT Neck Lungs Abdomen
Febrile or toxic appearing Skin Cellulitis, impetigo, rash ENT 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

30 Laboratory Workup CBC with Differential ESR Throat culture Serology
EBV, CMV, Toxoplasmosis, Bartonella, Syphilis, HIV PPD LDH, uric acid

31 Imaging Workup CXR if malignancy sus. Ultrasound Sometimes CT/MRI
To look for mediastinal lymphadenopathy Ultrasound Abscess? Benign vs. malignant Sometimes CT/MRI To evaluate for abscess EKG/ECHO If suspect Kawasaki Disease Biopsy FNA or Excisional

32 Summary History and Physical exam
Further workup with serology, imaging, and biopsy with resistant, subacute and chronic cases Ultrasound is a useful to characterize and differentiate reactive, suppurative, and malignant lymph nodes Sometimes Biopsy

33 The end

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