LYMPHADENOPATHY. By. Prof. Dr. Sameh Shamaa. Def.: It is an abnormal increase in size, or altered consistency of L.N . & is a clinical manifestation of regional or systemic disease & serve as an excellent clue to the underlying pathology and aetiology .
Prof. Dr. Sameh Shamaa
It is an abnormal increase in size, or altered consistency of L.N. & is a clinical manifestation of regional or systemic disease & serve as an excellent clue to the underlying pathology and aetiology.
2-Carcinomatous L.N. Draining a Malignant Tumour:
* hilar and scalene: bronchus.
* virchow’s: stomach
* cervical: thyroid, tongue, parotid.
3- Systemic Infections
* Viruses: a- Viral hepatitis Rt. supraclavecular L.N
b- L.G.V. --groin (ing LN)
c- German measles (cervical LN)
* Bacteria: a- Plague
* Spirochetes : (Iry $ draining chancer)
a- penis inguinal L.N.
b- lips submandibular L.N.
c-nipple axillary L.N.
* Protozoa a -Filarial infectious-----inuguinal L.N.
N.B Generalized L.N. may start as localized L.N. as in Hodgkin’s disease
a-Infectious mononucleosis b-Cytomegalo virus (C.M.V.)
* Bacteria: a- brucellosis
b- T .B.
1- Streptococcal infection of tonsils:
*Uni or Bilateral * Tender & unmatted
*Usually submandibular but may extend to lower cervical group.
2- Scarlet Fever
* Sore throat.
* marked enlargement of submandibularL.N.
*Other cervical L.N. (bilateral, tender, discrete, suppuration is common).
*Enlarged submandibularL.N. usually bilateral, tender, not matted.
*OccipitaIL.N. enlargement are nearly always present, closely resembles that of infectious mononucleosis.
* Sore throat, Fever, sometimes headache, myalgia.
* Bilateral L.N. enlargement, firm, discrete, mobile.
* Appear first in posterior cervical area, adjacent to cervical spines, few days later , submandibular L.N. will be enlarged
* Palatal petechiae often, are present
* Mild splenomegally in 50% of cases
*Lymphocytosisin 75% of cases with some atypical lymphocytes.
* The chiefly affected group is upper cervical group, generalized L.N. enlargement is exceptional.
* Unilateral or Bilateral.
* Often firm, matted, painful, may become adherent to skin or deep structures.
* Cystic areas may occur due to caseation and later on cold abscess formation.
*Overlying skin may break down giving T.B. ulcers or sinuses.
L.N draining a chancre
-Rocky hard, uni Or bilateral, not tender.
-Generalized L.N. enlargement especially posterior triangle of the neck or epitrochleargp
(slightly enlarged, shotty, discrete, painless).
*May be associated with constitutional symptoms.(anorexia, fever, weight loss, sweating, ….. etc).
* Pel Ebstein fever: may be observed in H.D., it is a period of fever lasting for few days or weeks alternating with longer or shorter apyrexial periods .
* L.N. usually discrete at start & not tender (but may become tender during febrile periods).
* L.N. may increase in size during pyrexial periods and decrease in size during apyrexial periods
*May be associated with general manifestations (fever, malaise, anorexia, headache, Hemorhagictendency)
a- Acute Leukaemia:
*Late, slightly or moderately enlarged
*Soft, discrete esp. cervical L.N. due to oral sepsis
*May be tender bone.
* May affect cervica1 L.N. but mostly all superficial L.N. are enlarged.
*The glands usually are (firm, not tender, not matted, usually moderately enlarged, but in advanced stages may be markedly enlarged)
*Rare to be manifested by L.N. enlargement.
*Firm, but some times hard.
*A stoney hard nodes fixed to underlying tissues are nearly always neoplastic in nature, however the reverse is not true.
*Carcinomatous L.N. may be freely mobile
* Constitutional symptoms (fever, sweating, loss of wt., pruritis)
* Pressure symptoms:
- Pressure on veins →oedema
- Pressure on nerves → pain
* T.B.: usually in children and young adults.
* H.D. : any age including childhood, but its highest incidence ( ) (20-40 ys)
* N.H.L.: usually at middle age and late life.
* Acute Leuk.: any age, but highest in first 6 years of life.
* of infections, drugs, or vaccinations.
* Localized or generalized.
* Single or multiple groups affected.
Characters mentioned before.
*Fever:Leuk., H.D., N.H.L., PelEbsteinfever.
*Jaundice :H.D.,Chronicleuk. (due to hepatic infiltration → pressure on bile duct)
*Eye: in leuk. (infections, sub conj. Hge., exophthalmos.)
* Mouth, Tonsils, Parotid, Gums.
2/3 moderately enlarged spleen.
I /3 moderately enlarged liver.
in Sarcoidosis :hepatosplenomegaly in 1/3 of cases
* Limbs : bone aches, swelling, joint affection.
- esp. M.D. & N.H.L.
- brain & spinal cord : Hge, meningeal infiltration, pressure manifest.
- peripheral nerves: pain, parathesia.
-mediastinum : Horner's syndrome, or vocal cords
*For cases of genera1ised lymphadenopathy or local L.N. enlargement without local cases:
(1) Complete clinical examinations.
(2) C.B.P. & E.S.R.
(3) Serological tests for infections mononucleosis,T.B. toxoplasmosis, $.
(4) Plain chest X ray.
(6) Bone marrow aspiration if leuk. is suspected from C.B.P.
* Biopsy should be done for enlarged L.N. of more than one month duration and not responding to usual ttt.
- +ve→ management.
- -ve (single reactive hyperplasia) →follow up & if persist repeat biopsy two months later.
Isolated Mediastinal L.N. Enlargement occurs in:
- H.D. & N.H.L.
- T.B. & Sarcoidosis.
- Cancer lung or oesophagus.
Isolated Abdominal L.N. Enlargement occurs in:
- H.D & N.H.L
A- Clinical staging:
1-Detaild history esp. in systemic symptoms.
2-Clinical examination including the Waldeyer's ring & areas of bone metastasis.
3-Adequate surgical biopsy
4- Routine lab. tests (C.B.P. & E.S.R & liver kidney function tests & Serum Uric acid.)
5- Plain chest X ray (P.A & Lat. view)
6- Bilateral lower extremities lymphangiography.
7- Radiological examinations (G.I.T., Gastroscopy if + veWaldeyer's ring)
8- Abdominal Ultrasonography or C.T. Scan.
1- Bone narrow biopsy.
2- Staging labarotomy. (only indicated in H.D with clinical stage I & II, if theraputic decision will depend on the identification of occult abdominal involvement) .
Stage I* Involvement of single L.N. region (I)
* Or single extra nodal organ or site (IE*)
*involvement of two or L.N region on the same side of the diaphragm (II).
*or. localised involvement of an extranodal organ or site will one or more L.N. regions on the same side of the diaphragm (IIE*).
III: involvement of L.N. regions on both sides of diaphragm.
IIIs: may be also accompanied by splenic enlargement
IIIE* : or by localized involvement of an extranodal site.
IIISE* : or both.
* Diffuse or disseminated involvement of one or more extranodal organs with or without associated L.N. involvement.