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