1. Lymphadenopathy: Approach in the Community Dr Chanpasong Family Medicine CME Conference, Champasack Provincial Hospital, Pakse October 2012

2. Where are the lymph nodes located in the body? What areas of the body do they drain?

5. Lymphadenopathy can be generalized… Lymphoma

6. …or localized Posterior auricular lymph node abscess from otitis media

7. When are palpable lymph nodes abnormal?

8. Lymphadenopathy Normal lymph nodes < 1 cm in diameter Larger in adolescence than adults Can often feel lymph nodes in healthy people ▫inguinal region (prior chronic trauma and infection) ▫neck (infections) Lymph nodes are abnormal if hard, irregular, rubbery, fixed to underlying tissue

9. What is the cause of the lymphadenopathy? Underlying cause is usually infection and self limited Must recognize when to look for more serious causes

10. Often clear from history and physical examination HISTORY ▫symptoms, exposure, sexual behavior, medications and drug use PHYSICAL EXAMINATION: ▫lymph node location, size, consistency, fixation, tenderness. LOCALIZED or GENERALIZED lymphadenopathy

11. Case # 1 Child with sore throat, fever, tender lymph nodes head and neck What is the cause of lymphadenopathy? Group A strep pharyngitis

12. Case # 2 Man, smoker, with tumor inside mouth What is the diagnosis? What lymph nodes will be affected? Oral cancer Submandibular, submental nodes, maybe deep cervical

13. Case # 3 Woman with weight loss, fevers, and lymphadenopathy What is the mouth abnormality? What is the cause of her adenopathy? Will it be local or generalized? Oral candidiasis HIV Generalized

14. Case # 4 Child with fever, sore throat, difficulty breathing, hoarseness, paralysis of the eye muscles What is the cause of the lymphadenopathy? What is this physical exam finding? Diphtheria “Bull neck” from lymphadenopathy

15. Case # 5 Lymphadenopathy with staph abscess in the infected axillary node Where is the primary skin infection? Arm, chest or neck

16. Case # 6 Woman with no appetite, weight loss, and throwing up blood What lymph node is enlarged? What is her diagnosis? Left supraclavicular node. (Virchow’s) Gastric cancer

17. Causes of lymphadenopathy CausesExamples Bacterial Localized Generalized Strep pharyngitis, skin infection, diphteria Leptospirosis, typhoid fever MycobacterialMycobacterium TB, atypical mycobacterium FungalCryptococcus, coccidiomycosis ViralHIV, Ebstein-Barr, Herpes simplex, mumps, measles, dengue fever, hepatitis B, rubella, varicella ProtozoalToxoplasmosis SpirochetalSecondary syphilis LymphoproliferativeLymphoma, leukemia EndocrineHypothyroidism, Addison’s disease ImmunologicalDrug reactions (phenytoin) MalignancyMetastatic disease OtherSLE, sarcoidosis, amyloidosis, rheumatoid arthritis

18. What if the lymphadenopathy is unexplained?

19. Unexplained lymphadenopathy Observe over time Localized lymphadenopathy (e.g. axilla) can be observed for three to four weeks but MUST follow up. Generalized lymphadenopathy should have a complete blood count and chest x-ray. Lab tests depend on clinical clues. ▫TB, HIV, syphilis, ANA (auto-immune) Imaging. ▫Regular x-rays not very helpful. ▫Ultrasound, CT can provide clues but cannot replace biopsy. Empiric antibiotics treatment is not useful

20. How do I decide when to do biopsy?

21. How do I decide to biopsy? BIOPSY IF ▫Pt has symptoms of malignancy (fever, night sweats, weight loss) ▫Pt age > 40 ▫Lymph node > 2 cm, or hard, irregular ▫Abnormal chest Xray ▫No infection symptoms ▫Supraclavicular location ▫Abnormal node has not resolved after observed four weeks Only 1 % of patients coming to family physician with unexplained lymphadenopathy have a malignancy.

22. ▫Open biopsy is usually the best diagnostic test ▫Core Needle Biopsy with Fine Needle Aspiration can be useful

23. Case # 7 15 year old boy who developed fever for 3 days, vesicular skin lesions and swollen occipital lymph node Primary Varicella infection (chicken pox )

24. Case # 8 60 year old man with difficulty urinating for the last year, noticed swelling in groin over the last 3 months Metastatic prostate cancer

25. Case # 9 Man, ill for two months with fever, cough, arthritis and skin lesions Chronic melioidosis

26. Case # 10 12 year old boy who feels unwell with fever for 2 months, weight loss of 5 kg and pruritus Hodgkin’s lymphoma

27. Case # 11 Child with chronic painless mass and bluish skin discoloration What is the name of this “cold abscess” condition caused by an atypical mycobacterium? Tuberculous cervical lymphadenitis caused by Mycobacterium scrofulaceum

28. Summary Most causes of lymphadenopathy are from infection and self-limited Must recognize when to look for more serious causes Use the history, physical examination, and location of the lymphadenopathy to help with diagnosis Follow up on unexplained lymphadenopathy

29. Lymphadenopathy(²½¨¾©¢º¤¡½©ñ­­Õµ¾¤À¹ìõº¤) History, Physical, Lab History, Physical, Lab Localized Lympha- denopathy ¡Éº­¡½©ñ­ ¥÷©Ã©­ ‡¤ Localized Lympha- denopathy ¡Éº­¡½©ñ­ ¥÷©Ã©­ ‡¤ Generalized Lympha denopathy ¡Éº­¡½©ñ­ ꉸį Generalized Lympha denopathy ¡Éº­¡½©ñ­ ꉸį Infection ¡¾­§ô´À§œº Infection ¡¾­§ô´À§œº Hematologic Malignancy ´½Àìñ¤Àìõº© Hematologic Malignancy ´½Àìñ¤Àìõº© Metastases ¡¾­Á°Èì¾´ Metastases ¡¾­Á°Èì¾´ Infection ¡¾­§ô´À§œº Infection ¡¾­§ô´À§œº Hematologic Malignancy ´½Àìñ¤Àìõº© Hematologic Malignancy ´½Àìñ¤Àìõº© Connective Tissue Disoders ²½¨¾©ê¾¤¥ó¸½ Connective Tissue Disoders ²½¨¾©ê¾¤¥ó¸½ Infection of Lymph Node (Adenitis) ªÈº´¡½©ñ­ ºñ¡À¦® Infection of Lymph Node (Adenitis) ªÈº´¡½©ñ­ ºñ¡À¦® Reaction to Regional Infection ¡¾­¡½êö®ªº® ¡¾­ §ô´À§œºµøÈ ¢º®À¢©Ã©­‡¤ Reaction to Regional Infection ¡¾­¡½êö®ªº® ¡¾­ §ô´À§œºµøÈ ¢º®À¢©Ã©­‡¤ Bacterial TB Viral Bacterial TB Viral Eg. Cervical Adenopathy from Otitis Media Eg. Cervical Adenopathy from Otitis Media Lymphoma ìò´Â³´¾ Lymphoma ìò´Â³´¾ Leukemia ìò¸£óÀ´¨ Leukemia ìò¸£óÀ´¨ Gastric cancer To supraclavicular node Gastric cancer To supraclavicular node Bacterial TB Syphillis Bacterial TB Syphillis Protozoa ¯ª§ö¸ Toxoplasmosis ªËº¡Â¦¯ù¾©Â´§ò © Protozoa ¯ª§ö¸ Toxoplasmosis ªËº¡Â¦¯ù¾©Â´§ò © Viral Eg. EBV, Rubella CMV, HIV Viral Eg. EBV, Rubella CMV, HIV SLE, RA SLE, RA TB- Tuberculosis EBV- Ebstein Barr Virus CMV- Cytomegalovirus SLE- Systemic Lupus Erythematosis RA- Rheumatoid Arthritis HIV- Humman Immunodeficiency Virus