Lymphadenopathy

A. Suryaveda
Aakanksha Sangwaan
Aishwarya
Alankar Parashar
The body has approximately 600 lymph nodes, but only those in the submandibular,
axillary or inguinal regions may normally be palpable in healthy people.

Lymphadenopathy refers to nodes that are abnormal in either size, consistency or

number. Size > 1cm except supraclavicular, popliteal, iliac and epitrochlear
nodes(>0.5cm).

Generalised vs Local Lymphadenopathy, Lymphadenopathy vs Lymphedema(Radiation,

Trauma, surgery, filariasis).

Presentation by Anatomic site.

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• The left subclavicular LN receives drainage from Thoracic Duct, so Virchows
node can be present in any GI, Genitourinary malignancies

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Causes of Lymphadenopathy
Generalized lymphadenopathy
 TB Lymphadenitis
• Lymphadenitis is the most common clinical presentation of extrapulmonary
tuberculosis.

• MC in Cervical LN, followed by Mediastinal, axillary, mesenteric, hepatic portal,

perihepatic and inguinal lymph nodes.

• Primary TB spreads from lung tissue(gohn focus) to hilar, paratracheal LN. The
Ghon focus and related hilar lymphadenopathy form the primary complex.

• Hilar, mediastinal and paratracheal lymphnodes are the first site of spread of
infection from the lung parenchyma.

• Cervical TB lymphadenitis(Scrofula) may represent a spread from the primary

focus of infection in the tonsils, adenoids sinonasal or osteomyelitis of the ethmoid
bone.

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• The onset of delayed hypersensitivity is accompanied by marked hyperemia, swelling,
necrosis and caseation of the centre of the nodes. Adhesion to the adjacent skin may result
in induration and purplish discolouration.

• This can be followed by progressive swelling and matting with other nodes within a group.
The centre of the enlarging gland becomes soft and caseous material may rupture into
surrounding tissue or through skin with sinus formation.

• Tuberculous mediastinal lymphadenitis may enlarge and cause compression of major blood
vessels, phrenic or recurrent laryngeal nerves. Mediastinal lymph node involvement include
dysphagia, oesophago-mediastinal fistula and tracheo-oesophageal fistula.

• Upper abdominal and mediastinal lymph nodes may cause thoracic duct obstruction and
chylothorax, chylous ascites or chyluria. Cardiac tamponade has also been reported due to
mediastinal lymph node tuberculosis.

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 Tb lymphadenitis staging
• Multiplicity, matting and caseation are features of TB lymphadenitis.

• Jones and Campbell classified peripheral tuberculous lymph nodes into

following five stages.

1. stage 1, enlarged, firm, mobile, discrete nodes showing non-specific reactive

hyperplasia;

2. stage 2, large rubbery nodes fixed to surrounding tissue owing to periadenitis;

3. stage 3, central softening due to abscess formation;

4. stage 4, collar-stud abscess formation;

5. stage 5, sinus tract formation.

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 Malignancy

• MC cause of lymphadenopathy is metastatic deposits of primary malignancy of

head and neck, breast, lung.

• Primary cancer of LN is Lymphoma.

• Hodgkins(10-14%, RS cells, EBV)

• NHL(80-90%, B-cell MC)

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 Infectious Vs NonInfectious

Differentiating features on History:

History Clues Ddx

History Clues Ddx
Differentiating features on Examination:

1. location, TB cervical group, filariasis Inguinal group, secondary syphillis

Epitrochlear and suboccipital group.
2. Skin over swelling, Inflamm. signs, ulcer, sinus, cold abscess.
3. consistency, soft, elastic, rubbery, firm, stony hard or variable
consistency(lymphosarcoma)
4. tender on palpation
5. matted lymph nodes - TB
6. fixity to surrounding structures
7. look out drainage area of a particular lymph node.
Cervical lymph nodes
Axillary Lymph Nodes
Inguinal Lymph nodes
Differentiating features on Investigations.

USG - Soft tissue edema and nodal matting on B-mode imaging suggest tubercular
cervical lymphadenopathy.

FNAC - abscess, acid fast staining, Frei’s intradermal test for lymphogranuloma inguinale,
atypical cells.

Radiology - calcified LN can be seen in X-ray, CT for mediastinal LN, Can Detect TB and
Carcinoma in X-ray.

Biopsy - TB Caseous necrosis, atypical cells, malignant cells in Malignancy. Reed

Sternberg cells in Hodgkins.

Lymphangiography - Irregular filling defect in LN means secondary metastasis. Soap

bubble appearance in Hodgkins. Coarse Nodular storage pattern in lymphosarcoma.
Marginal sunburst appearance in reticulum cell carcinoma.
 References

• American Association of Family physician, Approach to a

case of lymphadenopathy

• Uptodate, Approach to lymphadenopathy

ThankYou..