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Lymphadenopathy and Lymphadenitis Dr. Orli Megged SZMC.

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Presentation on theme: "Lymphadenopathy and Lymphadenitis Dr. Orli Megged SZMC."— 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 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  Phenytoin, Allopurinol …..  Immunizations  Smallpox (historically)  Live attenuated MMRV  BCG  Sarcoidosis

17

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  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 Atypical Mycobacteria Zeharia et al 2008

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

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 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. 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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