Lymphadenopathy

General principles
usually a result of benign infectious causes.
Mostly diagnosed on the basis of a careful
history and physical examination.
Localized adenopathy should prompt a search
for an adjacent precipitating lesion.
In general, cervical, axillary lymph nodes greater
than 1 cm and inguinal > 1.5 cm in diameter are
considered to be abnormal.
Generalized adenopathy should always prompt
further clinical investigation.
 Definition
Lymphadenopathy refers to nodes that are
abnormal in either size, consistency or number.
"generalized" if lymph nodes are enlarged in two
or more noncontiguous areas
"localized" if only one area is involved.
Generalized lymphadenopathy almost always
indicates the presence of a significant systemic
disease.
Lymphoid type
 Epidemiology
Population-based study (Dutch): 10% of patients
with unexplained adenopathy required referral to a
subspecialist, and only 1 percent had a malignancy

In primary care settings, patients 40 years of age

and older with unexplained lymphadenopathy have
about a 4 % risk of cancer versus a 0.4% risk in
patients younger than age 40.

(Fijten GH, Blijham GH. Unexplained lymphadenopathy in family practice. An evaluation of the
probability of malignant causes and the effectiveness of physicians' workup. J Fam Pract
1988;27: 373-6)
 Evaluation of possible
adenopathy
Is the swelling a lymph node?
Is the node enlarged?
What are the characteristics of the node?
Is the adenopathy local or genralized?
 Physical examination
Five characteristics should be noted and described:

Size. normal if < 1 cm in diameter;

Abnormal: epitrochlear nodes > 0.5 cm
inguinal nodes > 1.5 cm
Pain/Tenderness. inflammatory process or suppuration, hemorrhage into the
necrotic center of a malignant node.
Consistency. Stony-hard nodes: cancer, usually metastatic.
Very firm, rubbery nodes: lymphoma.
Softer nodes: infections or inflammatory conditions.
Suppurant nodes may be fluctuant.
"shotty" (small nodes that feel like buckshot under the skin)
cervical nodes of children with viral illnesses.
Matting. benign (e.g., tuberculosis, sarcoidosis or lymphogranuloma venereum)
malignant (e.g., metastatic carcinoma or lymphomas).
Location.
 Lymph Node Groups: Location, Lymphatic Drainage
and Selected Differential Diagnosis

Location Lymphatic drainage Causes

Submandibular Tongue, submaxillary gland, Infections of head, neck,

lips and mouth, sinuses, ears, eyes, scalp,
conjunctivae pharynx
Submental Lower lip, floor of mouth, tip Mononucleosis syndromes,
of tongue, skin of cheek Epstein-Barr virus,
cytomegalovirus,
toxoplasmosis
Jugular Tongue , tonsil, pinna, Pharyngitis organisms,
parotid rubella

Posterior cervical Scalp and neck, skin of Tuberculosis, lymphoma,

arms and pectorals, thorax, head and neck malignancy
cervical and axillary nodes
Suboccipital Scalp and head Local infection
 Lymph Node Groups: Location, Lymphatic Drainage
and Selected Differential Diagnosis
Location Lymphatic drainage Causes

Postauricular External auditory meatus, Local infection

pinna, scalp

Preauricular Eyelids and conjunctivae, External auditory canal

temporal region, pinna

Right supraclavicular node Mediastinum, lungs, Lung, retroperitoneal or

esophagus gastrointestinal cancer

Left supraclavicular node Thorax, abdomen via Lymphoma, thoracic or

thoracic duct retroperitoneal cancer,
bacterial or fungal infection
Axillary Arm, thoracic wall, breast Infections, cat-scratch
disease, lymphoma, breast
cancer, brucellosis,
melanoma
 Lymph Node Groups: Location, Lymphatic Drainage
and Selected Differential Diagnosis

Location Lymphatic drainage Causes

Epitrochlear Ulnar aspect of forearm Infections, lymphoma,
and hand sarcoidosis, tularemia,
secondary syphilis
Inguinal Penis, scrotum, vulva, Infections of the leg or
vagina, perineum, gluteal foot, STDs (e.g., herpes
region, lower abdominal simplex virus,
wall, lower anal canal gonococcal infection,
syphilis, chancroid,
granuloma inguinale,
lymphogranuloma
venereum), lymphoma,
pelvic malignancy,
bubonic plague
 Common causes of generalized
lymphadenopathy
Infections: Typhoid fever, TB, AIDS, mononucleosis, CMV,
rubella, varicella, rubeola, histoplasmosis, toxoplasmosis
Autoimmune diseases: RA, SLE, dermatomyositis
Malignancies:
primary: HD, NHL, histiocytic disorders,
metastatic: leukemia, NB, RMS
Lipid storage diseases: Gaucher, Niemann-Pick
Drug reactions
 Medications That May Cause
Lymphadenopathy

Allopurinol Penicillin
Atenolol Phenytoin
Captopril Primidone
Carbamazepine Pyrimethamine
Cephalosporins
Gold Quinidine
Hydralazine Sulfonamides
Sulindac
. Pangalis GA, Vassilakopoulos TP, Boussiotis VA, Fessas P.
Clinical approach to lymphadenopathy. Semin Oncol 1993; 20:570-82
 Common causes of regional node
enlargement
Occipital: roseola, rubella, scalp infections
Preauricular: cat-scrath disease, eye
infections
cervical: Streptococcal/staphyllococcal
adenitis or tonsillitis, mononucleosis,
toxoplasmosis, maligancies, Kawasaki
disease
Submaxillary: HD, NHL, tuberculosis,
histoplasmosis
 Common causes of regional node
enlargement
Axillary: infections of arm/chest wall, cat-
scratch disease, malignancies
Mediastinal: maligancies (T-cell
leukemia/lymphoma, thymoma, teratoma),
TB
Abdominal: malignancies, mesenteric
adenitis
Illioinguinal: infections of leg, groin
 Indication for biopsy
increase in size over baseline in 2 weeks

no decease in size in 4-6 weeks

no regression to normal in 8-12 weeks

development of new signs and symptoms

 Caution!
Biopsy should be avoided in patients with
probable viral illness because lymph node
pathology in these patients may sometimes
simulate lymphoma and lead to a false-
positive diagnosis of malignancy.

Fine-needle aspiration is occasionally

considered an alternative to excisional
biopsy but is often unhelpful.
 Final Comment

In most patients, lymphadenopathy has a readily diagnosable

infectious cause.

A diagnosis of less obvious causes can often be made after

considering the patient's age, the duration of the lymphadenopathy
and whether localizing signs or symptoms, constitutional signs or
epidemiologic clues are present.

When the cause of the lymphadenopathy remains unexplained, a

10-14 day (3-4-week) observation period is appropriate when the
clinical setting indicates a high probability of benign disease.