Approach to a patient with lymphadenopathy

HISTORY

• How long the swelling has been noticed and how it progressed:
  • Shorter duration:
    • Infectious: Bacterial (strep/staph)
    • Viral ( EBV, Rubella, Rubeola, HZV, CMV )
    • Acute Leukemia
    • Kawasaki
    • Drug reactions
  • Insiduous onset:
    • Toxoplasmosis, HIV, CSD
    • CML
    • SLE, JRA, JDM, sarcoidosis
    • Gauchers, Neiman Pick
  • Chronic Lymphadenopathy:
    • Tuberculosis, Ch. Otitis media, Tinea capitis, Seborrhoea, Head Lice
  • Age of onset: ALL (2-6y), Lymphoma (15-19y), Kawasaki <5yrs
  • Sex: Male: Trauma and wound infection, leukemia, lymphoma
    • Female: SLE, JRA
  • Progression: Rapidly increasing in size: Acute Leukemia, Metastasis Variable duration with increasing in size: Lymphomas
• Tenderness present:
  • Bacterial adenitis,
  • Malignancy with rapid growth and necrosis or with hemorrhage
• Discharge present: Bacterial adenitis, TB

GENERALIZED LYMPHADENOPATHY

Infections: TB, Rubella, rubeola, CMV, HIV, HTLV, Histoplasmosis, EBV, HZV, Toxoplasmosis
Malignancy:

• Primary: Hodgkin disease, non-Hodgkin lymphoma, histiocytic disorders, lymphoproliferative disease.
• Metastatic: Leukemia, neuroblastoma, rhabdomayosarcoma

Autoimmune diseases: Lupus erythematosis, Rhumatoid arthritis, Dermatomyositis.
Lipid storage disease: Gaucher disease, Niemann-Pick disease
Drug reaction: Carbamazepine, phenytoin, penicillin, sulphonamides, captopril
Others: Castleman disease, sarcoidosis, serum sickness

REGIONAL LYMPHADENOPATHY

Cervical:

• Strep/staph adenitis, Mycobacterial infections, IMN, Kawasaki disease, cat scratch disease, malignancies, sinus histiocytosis

Occipital: Roseola, rubella, scalp infections ( tinea)
Preauricular: Eye infections, cat scratch disease
Submaxillary: TB, Lymphoma, Histoplasmosis
Axillary:

• Infections of the arm/ chest wall, cat scratch disease, malignancies
• Mediastinal:
  • TB, malignancies (teratoma, T cell lymphoma, leukemia), sarcoidosis, Histoplasmosis.
• Abdominal:
  • TB, Mesenteric adenitis, Malignancies
• Ilioinguinal:
  • Infections of the leg or groin

History

• History of any localizing symptoms or signs:
  • Bacterial Infections: Sore throat, Ear/eye discharge, Trauma/ wound on the body
• Rash over body
  • Bacterial/viral infections, TB, Kawasaki, malignancy, metabolic diseases, drugs, SLE, JRA, JDM, histoplasmosis
  • Pruritis:
  • Hodgkins, Drug reactions
• Associated symptoms:
  • Fever: Infections, Leukemia, Lymphoma, other Malignancy, Drug reactions, JRA, SLE, Sarcoidosis.
  • Weight loss: Tuberculosis, HIV, Malignancy, Failure to thrive ( Gaucher’s and Nieman Picks)
  • Night sweats: Hodgkins lymphoma
  • Cough: Infections (TB), ALL, Lymphoma, sarcoidosis
  • Bone or joint pains: TB, Reactive arthritis viral infections, bacterial infections, Leukemia, Lymphoma, secondary malignancy (neuroblastoma), JRA, SLE, Kawasaki, Gaucher’s.
  • Bleeding from any site: Malignancy, Bacterial sepsis
  • Abdomen distension: TB, HIV, Leukemia, Lymphoma, Systemic onset JRA, SLE, Gaucher’s, NPD, Sarcoidosis
  • Jaundice: CMV, HIV, HBV, Lymphoma, Secondary malignancy
  • Altered bowel Habits: TB, HIV, JDM, SLE (male and/diarrhea)
  • SOB or breathing difficulty: Mediastinal mass, cardiac involvement
  • Dysphagia: NHL, TB, rhabdomyosarcoma, histoplasmosis
  • Visual problem: neuroblastoma
  • Hematuria: SLE, TB, rhabdomyosarcoma
• Past medical history:
  • H/O TB, recurrent or other chronic infection, history of blood transfusion (CMV, HIV)
• History of contact with TB, pet in the family (Toxoplasmosis, cat scratch disease)
• Dietary history: intake of undercooked meat (Toxoplasmosis)
• History of drug ingestion/treatment taken.
• History of immunization (MMR)
• Development history ( Gaucher’s, NPD)
• Family history: similar complaints, TB or any chronic Illness. HIV
• Occupation and Age of parents: HIV, Downs syndrome

General Examination:

• Anthropometry: Ht, Wt, (TB, malignancy) OFC Downs syndrome

• Vitals:
  • HR fever, anemia
  • Irregular: viral myocarditis, strep, myocardial infiltration (Hodgkins), SLE, JDM, Kawasaki disease
  • BP: SLE, neuroblastoma

Local Examination:

• Inspection: Number, position, the surface of LN
• Palpation: Site, number, local temperature, tenderness, surface and margins, matted +/-, fixidity to surrounding structure or skin
• Node character
  • Bacterial adenitis: regional, discrete, Tender, overlying erythema, +/- fluctuation
  • TB: nontender matted, +/- draining sinus
  • Hodgkins: Nontender, rubbery in consistency
  • Malignancy: Firm to hard, fixed to an underlying structure or overlying skin
  • Multiple nodes involved: generalized lymphadenopathy

 

source: AAFP

General survey

• Pallor: TB, HIV, CMV, EBV, Bacterial sepsis, CSD malignancy (Leukemia, Lymphoma), JRA, SLE, JDM, Gaucher’s, NPD

• Icterus, Cyanosis, Pedal edema, Clubbing
• JVP ( Lymphoma)
• Rash over body
  • Petechiae: Bacterial sepsis, CSD, Viral infections (HIV, EBV, measles), Leukemia, secondary malignancy, SLE, Gaucher’s, Neiman Picks disease, Drug.
  • Skin nodules: GAS, TB, AML, CML, Hodgkins, TB, Sarcoidosis, histoplasmosis, Drugs (sulphonamides) neuroblastoma

• Dysmorphism: Downs syndrome ALL + AML
• Bony tenderness: Leukemia, Malignancy
• Oral Examination:
  • Strep pharyngitis,
  • Petechiae in oral mucosa
  • Gum bleeding
  • Gum hypertrophy (AML)
  • Oral ulcers: Leukemia, SLE, JDM
  • Strawberry tongue: Kawasaki
• Ear examination:
  • Bacterial infections
  • Otorrhoea: TB, rhabdomyosarcoma
• Eye examination
  • Conjunctivitis: bacterial/viral infection, Kawasaki dis.

• Phlycten: Tuberculosis
• Uveitis : JRA
• Inflammatory reaction: SLE, Sarcoidosis
• Chorioretinitis: Toxoplasmosis
• Retinal Hemorrhages: Acute Leukemia
• Eye lid talangiectasia: JDM
• Cherry red spot: NPD, Gauchers disease
• Proptosis: Neuroblastoma
• Vision: neuroblstoma, rhabdomyosarcomy, JRA

Systemic Examination:

• P/A Abd.
  • Distension
  • Hepatosplenomegaly: Tuberculosis, HIV, EBV, Rubella, Leishmaniasis, Bacterial sepsis, Histoplasmosis, Leukemia, Lymphoma, JRA, SLE, Gaucher’s, NPD
  • Hepatomegaly: Sarcoidosis
  • Splenomegaly: IMN, massive CML, Gaucher’s
  • Abdominal mass or ascites: TB, Malignancy
• Chest:
• Tracheal deviation ( Lymphoma)
  • B/L air entry or added sounds
  • Pleural effusion: TB, Bacterial inf, lymphoma, JRA, SLE
  • Infiltrates: Malignancy, NPD
  • Others: Sarcoidosis interstitial fibrosis
• CVS: any murmurs, pericardial effusion, TB, Viral myocarditis, Kawasaki, lymphoma, JRA, SLE, JDM

• Nervous System:
  • General or focal neurological signs

Investigations

• CBC
  • Hb: TB, HIV, CSD, Back sepsis, malignancy, SLE, JRA, Gaucher’s, NPD
  • TLC: Infections, Leukemia, JRA, HIV, SLE

• Neutrophils: Bacterial infections, CML ALL, NHL, HIV, drugs (penicillin)

• Lymphocytes: viral inf, TB, ALL HIV, Hodgkins (advanced), SLE, JDM

• Eosinophilia: TB, Toxoplasmosis, Hodgkins, sarcoidosis
• Basophilia: CML
• ESR: TB, Hodgkins, CSD, JRA
• Platelet: JRA, CML back. sepsis, HIV, EBV, CSD, Leukemia, 2º malignancy, SLE, JRA, JDM, Gaucher’s, NPD

• P/S: Blast cells +/- ALL, AML, CML
• Bone marrow examination: Leukemia, Leishmaniasis, Neuroblastoma, Gaucher’s, NPD
• Montoux: TB
• CXR
  • Pneumonitis: Bact/ viral inf, infiltrates malignancy
  • Hilar Lymphadenopathy: TB, ALL, Hodgkins, NHL, Sarcoidosis, HIV
  • Cardiomegaly: TB, HIV, rubella, HZV, EBV, GAS, Kawasaki, SLE, JRA, JDM, Drugs( sulphonamides)
• Echocardiography: Kawasaki disease
• C/S Blood, Pus, Throat
• Biopsy of Lymph node: Indicated if
  • Persistent or unexplained fever, weight loss, night sweats, hard nodes or fixation to surrounding tissue
  • Increase in size over baseline in 2 Wks
  • No decrease in size in 4-6 Wks
  • No regression to normal in 8-12 Wks
  • Development of new signs and symptoms
• Serology: HIV, HBV, EBV
• ANA: JRA, SLA
• dsDNA: SLE
• Uric acid malignancy
• Calcium: sarcoidosis, Tumour lysis syndrome (P, K) NHL

• Cu & ferritin: Hodgkins lymphoma
• LFT: HBV, EBV, Malignancy
• RFT: Before chemotherapy JDM, Sarcoidosis, sepsis, HIV
• CT/MRI: Malignancy
• Bone scan: Malignancy

Management

• General management:
  • Stabilize patient:
    • Maintain airway
    • Establish circulation
    • Blood / platelet transfusion
    • Fluid and electrolyte balance
  • Supportive care
    • Antibiotics prophylactic if neutropenia +
    • Pain management
    • Nutritional management
    • Psychological support
  • Specific management:
    • Antibiotics for bacterial infections
    • Antiviral if indicated HIV, HZV
    • Malignancy: chemotherapy, surgery or radiation as indicated
    • Collagen vascular disease: NSAID, steroids