Approach to

Lymphadenopath
y
dr Putra Hendra SpPD
UNIBA

The Lymphatic System

Because lymph
flows only toward
the heart, the
lymphatic vessels
form a one-way
system rather than
a full circuit

The Lymphatic System

There are
several
orders of
vessels

Lymph
capillaries
Lymphatic
collecting
vessels
Lymph nodes
Lymph trunks
Lymph ducts

The Lymphatic System

Tissue fluid is
continuously
leaving and reentering the blood
capillaries
For complex
reasons slightly
more fluid arises
from the arteriole
end than re-enters
the venule end
This amounts to
about 3 liters a day

Lymph Nodes

Fibrous strands
of connective
tissue called
trabecule
extend inward
to divide the
node into
compartments

Definition

Approx 600 LN in
body
LAN = abnl size,
number, consistency
Generalized vs
Local
Peripheral (central
LAN presents
differently)

Lymph Nodes

Anatomy
Collection of lymphoid cells attached to
both vascular and lymphatic systems
Over 600 lymph nodes in the body
Function
To provide optimal sites for the
concentration of free or cell-associated
antigens and recirculating lymphocytes
sensitization of the immune response
To allow contact between B-cells, T-cells
and macrophages
Lymphadenopathy - node greater than 1cm
in size

Why do lymph nodes

enlarge?

Increase in the number of benign

lymphocytes and macrophages in response
to antigens
Infiltration of inflammatory cells in
infection (lymphadenitis)
In situ proliferation of malignant
lymphocytes or macrophages (tumor lokal)
Infiltration by metastatic malignant cells
Infiltration of lymph nodes by metabolite
laden macrophages (lipid storage diseases)

Epidemiology

0.6% annual incidence of

unexplained adenopathy in the
general population
10% were referred to a subspecialist
and 3.2 % required a biopsy and
1.1% had a malignancy

Epidemiology

Larsson et al. 38-45% of normal children

have palpable cervical lymphadenopathy
Park et al. 90% of children aged 4-8 have
lymphadenopathy
DD:
Congenital Masses
Malignancies
Local presentation of systemic disease

Physical Exam

General
Febrile or toxic appearing
Skin
Cellulitis, impetigo, rash
HEENT
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
Extremities
Inguinal and Axillary adenopathy

When to worry?
Age :Age > 40, malignancy is more common
2. Characteristics of the node :
ukuran, konsistensi, nyeri tekan
3. Location of the node: Supraclavicular
1.

has the highest risk of Malignancy

4. Clinical setting associated with

lymphadenopathy : demam, anemi,
batuk

EXAMINATION OF A
LUMP
Size : When to worry 1.5-2cm in size
Consistency:
1. Hodgkins rubbery
2. Tuberculosis matted
3. Metastatic cancer craggy
4. Calcified stony hard
Tenderness: infectious mononucleosis,
dental sepsis, tonsilitis
Fixation: malignancy
Clearly demarcated
Duration and Rate of Growth (lama, cepat)

Presentation of
lymphadenopathy

Unexplained
lymphadenopathy
3/4 presents with
localized
1/4 present with
generalized

Posterior Cervical LAN Mono

Mycobacterial Adenitis Scrofula

Lymphatic spread of M.
tuberculosis as well as atypical
mycobacteria (M. scrofulaceum,
MAI)

Mycobacterial
Lymphadenitis

TB abscess

as part of immune reconstitution syndrome

Diagnostic Tests

Fine needle aspiration biopsy

(FNAB)
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Ultrasonography
Radionucleotide scanning

Role of Ultrasound
(Ahuja et al. 2005)

No radiation exposure
Good for following the progress of an abscess
Sensitivity 95% and Specificity 83% for differentiating reactive vs
metastatic lymph nodes
Differentiate Reactive vs Malignant nodes
Reactive
<1 cm
Oval (S/L ratio <0.5cm)
Normal hilar vascularity
Low resistive index with high blood flow
Malignant
>1 cm
Round (S/L ratio >0.5cm)
No echogenic hilus (hilus tak jelas)
Cogaulative necrosis present
High resistive index with low blood flow
Extracapsular spread (menyebar)

Fine Needle Aspiration

Biopsy

Standard of diagnosis
Indications
Any neck mass that is not an obvious
abscess
Persistence after a 2 week course of
antibiotics

Small gauge needle

Reduces bleeding
Seeding of tumor not a concern

No contraindications (vascular ?)

Fine Needle Aspiration

Biopsy

Differential Diagnosis

Lymphadenitis

Very common, especially within 1st decade

Tender node with signs of systemic infection
Directed antibiotic therapy with follow-up
FNAB indications (pediatric)

Actively infectious condition with no response

Progressively enlarging
Solitary and asymmetric nodal mass
Supraclavicular mass (60% malignancy)
Persistent nodal mass without active infection

Generalized
Lymphadenopathy

Malignancy lymphoma, leukemia, Kaposis

sarcoma, metastases
Autoimmune SLE, RA, Sjogrens syndrome,
Stills disease, Dermatomyositis
Infectious Brucellosis, Cat-scratch disease,
CMV, HIV, EBV, Rubella, Tuberculosis,
Tularemia, Typhoid Fever, Syphilis, viral
hepatitis, Pharyngitis
Other Kawasakis disease, sarcoidosis,
amyloidosis, lipid storage diseases,
hyperthyroidism, necrotizing lymphadenitis,
histiocytosis X, Castlemens disease

Drug Induced
Lymphadenopathy
Medications

Phenytoin
Pyrimethamine
Allopurinol
Phenylbutazone
Isoniazide
Immunizations
Smallpox (historically)
Live attenuated MMR
DPT
Poliomyelitis
Typhoid fever
**Usually self limited and resolves with cessation of medication
or with time in the case of immunization induced LAD

Inguinal LAN

STDs
Tinea infections (pedis/cruris)
Pelvic/Genital Malignancy
(squamous/melanoma)
Bubonic Plague? - was there an
exposure?
Lymphoma

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