Lymphadenopathy
Julie Adkins, Jill C. Cash, Beverly R. Byram, Cheryl A. Glass, Kristin Ownby, and Pat Obulaney
Definition
Lymphadenopathy is enlargement of a lymph node, manifested in benign, self-limiting diseases and in those that are incurable and fatal. Only small lymph nodes in the neck, axilla, and groin are palpable in normal individuals. Palpable nodes in other regions, or any node exceeding 0.5 cm in size, are potentially abnormal. The body has approximately 600 lymph nodes. There are different categories of lymphadenopathy:
A.Localized adenopathy.
B.Hilar adenopathy.
C.Generalized lymphadenopathy.
D.Other lymphatic abnormalities that present in other ways, such as lymphangitis, lymphadenitis, and lymphedema.
Incidence
A.Lymphadenopathy is a very common presenting symptom. Age is an important diagnostic factor: In patients younger than age 30, the cause proves to be benign in 80% of cases; in patients older than age 50, the rate of benign disease falls to 40%. In primary care patients with unexplained lymphadenopathy, approximately three-fourths of patients will present with localized lymphadenopathy and one-fourth with generalized lymphadenopathy.
Pathogenesis
A.Inflammation and infiltration are responsible for pathologic enlargement. Localized lymphadenopathy may represent the spread of disease from an area of drainage. The left supraclavicular node is referred to as the sentinel
node, which is in contact with the thoracic duct and drains much of the abdominal cavity. The right supraclavicular node drains the mediastinum, lungs, and esophagus. Generalized lymphadenopathy often results from infection, malignancy, hypersensitivity, and metabolic disease. Ninety percent of palpable supraclavicular nodes are a malignancy in patients 40 years of age or older.
Predisposing Factors
A.High risk of exposure to HIV:
B.Occupational exposure.
C.History of pharyngitis, upper body infections (head and neck), or intraoral infection.
D.Exposure to animals: Cats, sheep, cattle, rodents, deer ticks.
E.Travel to the southwest United States.
F.Exposure to bird droppings.
G.Lacerations sustained from gardening.
H.Exposure to tuberculosis (TB).
I.History of sexual exposure resulting in sexually transmitted infections (STIs).
J.History of tobacco abuse.
K.Cancer.
L.Anticonvulsant drugs that cause skin rash, fever, hepatosplenomegaly, and eosinophilia; for example, phenytoin (Dilantin).
M.Other medications:
1.Hydralazine.
2.Para-aminosalicylic acid.
3.Allopurinol.
Common Complaints
A.Sore throat.
B.Fever.
C.Fatigue and malaise.
D.Loss of appetite.
E.Unintentional weight loss.
F.Swollen, painless lumps in neck.
Other Signs and Symptoms
A.May feel good
except for finding enlarged lymph node.
B.Node location(s). For inguinal enlargement, rule out conditions that may resemble inguinal or femoral lymphadenopathy: Hernias; ectopic testicular, endometrial, or splenic tissue; lipomas; varices; and aneurysms. If inguinal area is painful and tender, it is most frequently caused by STIs.
C.Skin rash.
D.Bruising or petechiae.
E.Pruritus.
F.Erythema of skin or scalp.
G.Skin eruption.
H.Night sweats.
I.Enlarged and tender abdomen, abdominal pain.
J.Joint pain.
K.Significant fever, night sweats, and unexplained weight loss are known as B symptoms
and suggest lymphoproliferative disorders.
L.Painful nodes after drinking alcohol suggests Hodgkin’s lymphoma.
Subjective Data
A.A comprehensive and detailed history is necessary for diagnosis (see section Predisposing Factors
earlier). Review the onset, course, and duration of symptoms.
B.What does the patient note with respect to location, tenderness or painfulness, softness or hardness, and mobility of lymph nodes? Has the patient noticed more than one enlarged lymph node?
C.Review the patient’s history of IV drug use. Review risk factors for HIV.
D.Review history for hobbies, specifically gardening and camping, and occupation (see sections Toxoplasmosis
and Lyme Disease
of Chapter 18).
E.Review medications: Prescription, over-the-count (OTC), and herbal remedies.
F.Determine whether the patient has a fever or a known valvular heart disease.
G.Review any other associated symptoms or signs.
H.Review any recent exposure to family and friends with infections. Has the patient had recent immunizations?
I.Review recent dental problems or abscessed teeth.
J.Note whether the patient is a smoker. If so, how much, for how long, and when did the patient quit smoking?
K.Review the patient’s history for recent cat scratches.
L.Review the patient’s history for recent travel.
M.Review the patient’s history for new sexual partners, to rule out STIs.
N.Review usual weight and any recent weight loss, noting how much over what period of time.
O.Elicit information about similar symptoms in the past, when they occurred, how they were treated (antibiotics, biopsy), and the success of the treatment.
P.Elicit information about alcohol intake, noting how much, how long, and, if the patient has quit, how long ago.
Physical Examination
A.Check temperature, pulse, respirations, blood pressure, and weight.
B.Inspect:
1.Conduct a funduscopic exam.
2.Examine the eyes, ears, nose, and throat.
3.Conduct a dermal exam, and check mucous membranes for a primary inoculation site; this
may be a clue to a diagnosis of cat-scratch disease (CSD). A red lymphangitic streak may indicate a localized infection.
C.Palpate:
1.Palpate the abdomen. Splenomegaly frequently present with mononucleosis, lymphomas, and sarcoidosis.
2.Conduct a clinical breast exam. Palpate mass to determine if it is a lymph node, if applicable.
3.Palpate all nodal areas for localized and generalized lymphadenopathy:
a.Hard, fixed nodes suggest metastasis, and a biopsy should be taken promptly. Size alone is not itself diagnostic; any node larger than 3 cm suggests neoplastic disease.
4.Palpate the scalp in the elderly for the tender arteries of cranial arteritis.
5.Palpate the neck for thyroid gland tenderness.
D.Percuss: Percuss sinuses for tenderness, and transilluminate for evidence of sinusitis.
E.Auscultate: Auscultate the heart and lungs.
F.Musculoskeletal system exam:
1.Assess for bone or joint swelling, tenderness, and increased warmth.
2.Examine lower extremities for evidence of phlebitis: Asymmetric swelling, calf tenderness, and palpable cord.
G.Genitorectal exam:
1.Conduct careful external evaluation for herpetic lesions, masses, discharge, erythema, chancroid, scabies, and pediculosis.
2.Milk
urethra for discharge.
3.Note any folliculitis if the patient regularly shaves genital area.
4.Female pelvic exam: Look for cervical discharge, cervical motion tenderness, adnexal tenderness, and mass or heat
in the pelvis.
5.Males: Examine the prostate and testicles for tenderness and masses, as well as the penis for discharge and rash.
6.Examine the rectum for discharge, tenderness, masses, and fistulas.
Diagnostic Tests
A.Complete blood count (CBC) with differential.
B.Peripheral blood smear: The most useful laboratory test; may be helpful in the diagnosis of chronic leukemia, infectious mononucleosis, and other viral illnesses.
C.Blood chemistries.
D.Liver function tests, especially alkaline phosphatase.
E.Angiotensin-converting enzyme (ACE) test.
F.Antinuclear antibodies (ANA) and rheumatoid factor.
G.Rapid plasma reagin (RPR) and microhemagglutination assay for antibody to Treponema pallidum (MHA-TP), to rule out syphilis.
H.Heterophile test, to rule out mononucleosis.
I.Enzyme-linked immunosorbent assay (ELISA) and western blot, to rule out HIV.
J.Uric acid: Elevations may reflect lymphoma or other hematologic malignancies.
K.Blood cultures.
L.Urethral or cervical cultures and smears.
M.Throat culture.
N.Chest x-ray.
O.Mammogram with ultrasonography of suspicious breast area, if indicated.
P.After consultation:
1.Abdominal ultrasonography or CT scan, if indicated.
2.Biopsy or fine-needle aspiration: Fine-needle aspiration is used to obtain a cytologic diagnosis of a suspected cancer. False negative results may occasionally occur.
3.Lymph node biopsy: Lymph node biopsy is the definitive test to confirm or rule out a suspected neoplastic process.
4.Mediastinoscopy.
Q.Tuberculin skin testing (PPD) and the ACE determination can facilitate assessment:
1.If the patient tests negative for ACE and PPD and is Caucasian, then bronchoscopy and mediastinoscopy may be necessary to rule out lymphoma. If the patient tests positive for ACE but negative for PPD, then the probability is very high that sarcoidosis is the cause.
2.If the patient tests negative for ACE but positive for PPD, then primary TB is likely.
Differential Diagnoses
A.There are four general categories for lymphadenopathy:
1.Infections:
a.Mononucleosis.
b.AIDS or AIDS-related complex (ARC): Generalized adenopathy in an asymptomatic HIV-infected patient indicates a high risk of progression to AIDS. The lymphadenopathy represents follicular hyperplasia in response to HIV infection.
c.Toxoplasmosis.
d.Secondary syphilis.
e.Cytomegalovirus.
f.Epstein–Barr virus.
2.Hypersensitivity reactions:
a.Serum sickness.
b.Phenytoin and other drugs.
c.Vasculitis: Lupus and rheumatoid arthritis (RA).
3.Metabolic diseases:
a.Hyperthyroidism.
b.Lipidoses.
4.Neoplasia:
a.Leukemia.
b.Hodgkin’s disease, advanced stages.
c.Non-Hodgkin’s lymphoma.
B.Causes can be isolated by site of the enlarged nodes (see Table 20.1).
Plan
A.General interventions:
1.Pay careful attention to nodal history and characteristics on physical examination.
2.Make a careful assessment to establish that the palpable mass is a lymph node. Chronicity alone is not always serious.
B.Patient teaching:
1.As indicated by the particular disease process causing the lymphadenopathy. See the relevant guidelines.
C.Pharmaceutical therapy: Dependent on the diagnosis.
Follow-Up
A.Follow the patient closely to evaluate resolution of lymphadenopathy and disease process.
B.Follow-up depends on the diagnosis.
Consultation/Referral
A.Consultation with a physician may be useful if a period of observation is needed.
B.Refer the patient to a specialist after initial workup, if indicated.
TABLE 20.1 Causes of Lymphadenopathy by Site of Enlarged Nodes