Post on 13-Nov-2014
description
Clinical approach to Lymphadenopathy
EVALUATION OF LYMPHADENOPATHY
Nearly 600 lymphnodes
Normally palpable
Sub mandibularAxillary
inguinal
Pathophysiology
React to threat
Hyperplastic response that usually resolves within 1 month
Clinical presentations
1.Size & quality
Palpable nodes in other regionsAny node >1cm
abnormal
Nodes >3cm neoplasm
2.Accompanying symptoms
2.Accompanying symptoms
r/c fever >38.5 C,night sweats,weigt loss
LYMPHOMAS
Lymphngectic streaking
splenomegaly
3.Distribution
GENERALISED
•IMN•AIDS•AIDS related complex•Toxoplasmosis•Secodary syphilis
infections
•Serum sickness•Phenytoin•Vasculitis,lupus,RA
Hypersensitivity
•LEUKEMIA•HODGKIN’S DISEASE•NHL
Neoplasia
METABOLIC •Hyper thyroidism•Lipidoses
Castleman’s disease
Rare,idiopathic,Localised/multicentric,mimic lymphoma/HIV,systemic symptoms,increased risk of infection
LOCALISED•Viral Conjunctivitis•Trachoma•Tularemia•Sarcoidosis
ANT.AURICULAR
•Rubella•Scalp infection
POST.AURICLA
R
ANT. AURICULAR POST. AURICULAR
• Buccal cavity infection• Pharyngitis• Nasopharyngeal tumour• Thyroid malignancy
SUB MANDIBULAR
•IMN•Sarcoidosis•Toxoplasmosis•pharyngitis
CERVICAL B/L
SUB MANDIBULAR CERVICAL B/L
• Pulmonary malignancy• Mediastinal malignancy• Esophageal malignancy
Right Supra
clavicular
• Intra abdominal malignancy
• Renal ca• Testicular or ovarian
malignancy
Left supra
clavicular
RIGHT SUPRA CLAVICULAR LEFT SUPRA CLAVICULAR
•Ca breast / infection•Upper extremity infection
axillary
•Syphilis(b/l)..Sailor’s handshake•CLL•IMN•Lymphoma•Hand infection(u/l)
Epitrochlear
AXILLARY LYMPHADENOPATHY
EPITROCHLEAR LYMPHADENOPATHY
•Syphilis•Genital herpes•Lympho granuloma venereum•Chancroid•Lower extremity/local infection
Inguina
l
INGUINAL LYMPHADENOPATHY
•Lymphoma•Bronchogenic ca•TB•sarcoidosis
Hilar(u/l)
•Sarcoidosis•Fungal(histoplasmosis,coccidiomycosis)•Lymphoma•Bronchogenic ca•TB
Hilar(b/l)
UNILATERAL HILAR LYMPHADENOPATHYBILATERAL HILAR LYMPHADENOPATHY
•Adeno ca of gut•Hodgkin’s d/s•TB•Bladder ca•Gastric ca
ABDOMINA
L
GASTRIC CA
SISTER MARY JOSEPH NODULE
•Cat scratch fever•Hodgkin’s d/s•NHL•Leukemia•Metastatic ca•Sarcoidosis•Granulomatous infection
ANY REGION
CAT SCRATCH D/S
4.other lymphatic abnormalitiesLymphangitisLymphadenitisKikuchi’s diseaselymphedema
History & examination
1.Is the palpable mass indeed a lymph node????
Enlarged parotidThyroglossal cystAbscessBranchial cyst
2.Acute or chronic ??
3.Character of enlarged node???tender.,mobile
Firm,rubbery,nontenderPainless,stonehard,fixed&matted
4.Localized or generalised??
5.Are there associated systemic/localizing symptoms/signs???
6.Are there unusual epidemiological clues???
Exposure to catsTravelExposure to bird droppingsLacerations during gardeningExposure to TBSexual exposure
Laboratory investigations
1.Complete blood cell count with differential….
Atypical lymphocytosisEosinophiliaPancytopenia
2.Serum uric acid
3.Serum liver chemistries
Localised adenopathy
1.Throat culture
2.Urethral/cervical swabs
3.Blood culture
4.biopsy
5.Abdominal CT
6.Bone marrow biopsy
Heterophile testVDRLAntibody titres of viruses,fungi,toxoplasmosisAnti nuclear antibodiesRheumatoid factor
1.Serological tests
Generalised adenopathy
Hilar adenopathy
1.Mantoux test
3.ACE enzyme determination
4.Bronchoscopy
5.mediastinoscopy
2.chest X-RAY,CT
Lymph node biopsyMost direct approach
Indications
Approaches & yeild Excitional biopsy
prefferedFNACNeedle aspiration
Choice of nodeLargest nodeAvoid inguinal & axillarySupra clavicular-highest diagnostic yield
complicationsFollow up/empiric treatment
THANKZZZZZZZZ…..ZZZZZZ…..ZZZZ