LENFADENOPATHYLENFADENOPATHY

DEFINITIONDEFINITION

abnormality of the lymph nodes in abnormality of the lymph nodes in terms of number, hardness, and terms of number, hardness, and volumevolume

LAPLAP

Generalized Generalized LAPLAP::

two or more two or more seperate lymph seperate lymph node group are node group are effected.effected.

Localized LAPLocalized LAP::

one or more one or more lymph nodes in lymph nodes in the same region the same region are effectedare effected

EpidemiologyEpidemiology

Rece is not a major criteria.Rece is not a major criteria.

Sex: M/F=1Sex: M/F=1

Age: most frequent in younger children, Age: most frequent in younger children, less frequent in newborn.less frequent in newborn.

PathophsiologyPathophsiology

Increase in the number of benign lymphocytes and Increase in the number of benign lymphocytes and macrophages in the process of response to antigensmacrophages in the process of response to antigens

Infiltration of the lymph nodes with the inflammatory Infiltration of the lymph nodes with the inflammatory cells during infectioncells during infection

Infiltration of the lymph nodes with metastatic Infiltration of the lymph nodes with metastatic malignant cellsmalignant cells

In situ proliferation of lymphocytes and macrophagesIn situ proliferation of lymphocytes and macrophages Infiltration of the lymph nodes with metabolite-laden Infiltration of the lymph nodes with metabolite-laden

macrophages during storage diseasesmacrophages during storage diseases

I. Generalized I. Generalized LenfadenopahyLenfadenopahy

A- InfectionA- Infection

B- B- Neoplastic Neoplastic veve proliferative disorders proliferative disorders

C- Storage diseasesC- Storage diseases

D- AuD- Autoimmutoimmune disorders and ne disorders and hypersensitivity reactionshypersensitivity reactions

A- InfectionsA- Infections

1- Viral:1- Viral:

- Generalized upper respiratort tract - Generalized upper respiratort tract infectionsinfections

- Infectious mononucleosis- Infectious mononucleosis

- - CMV CMV

- - AAIDSIDS

- chickenpox- chickenpox

- measles- measles

A- InfectionsA- Infections

2-Bacterial2-Bacterial

- - SeptiSeptissemia emia

- - Typhoid feverTyphoid fever

- - Tb Tb

- - SyphilisSyphilis

A- InfectionsA- Infections

3- 3- Protozoal - ToxoplaProtozoal - Toxoplazzmosismosis

4- 4- Fungal - CoccidiomycosisFungal - Coccidiomycosis

B- B- Neoplastic and Neoplastic and PProliferative Disordersroliferative Disorders

Acute leukemiaAcute leukemia Lymphomas (Hodgkin, non-Hodgkin) Lymphomas (Hodgkin, non-Hodgkin) NeuroblastoNeuroblastomama HistiocytosisHistiocytosis

C- Storage diseasesC- Storage diseases

Gaucher Gaucher Niemann-Pick Niemann-Pick

D- OD- Otoimmune disorders and toimmune disorders and HyHypersensitivitypersensitivity reactionsreactions

JJuuvenile rhvenile rhoomatoid arthritismatoid arthritis (JRA) (JRA) Systemic lupus erythematosus Systemic lupus erythematosus Drug reactions (egDrug reactions (eg:: fen feniitoin, allopurinol) toin, allopurinol) Serum sicknessSerum sickness

2- Localized2- Localized lymphadenopathy lymphadenopathy

CervicalCervical Submaxillary and submental Submaxillary and submental Occipital Occipital PreauricularPreauricular Mediastinal Mediastinal SupraclavicularSupraclavicular Axillary Axillary Abdominal Abdominal InguinalInguinal

CervicalCervical

Viral URTIViral URTI IMIM Rubella Rubella Cat scratch diseaseCat scratch disease Streptococcal Streptococcal

pharyngitispharyngitis AcuteAcute bacterial bacterial

lymphadenitis lymphadenitis ToxoplasmosisToxoplasmosis

Tb/atypical Tb/atypical mymyccobacterial obacterial infectioninfection

Acute leukemiaAcute leukemia Lymphoma Lymphoma NeuroblastomaNeuroblastoma RhabdomyosarcomaRhabdomyosarcoma Kawasaki diseaseKawasaki disease Nasopharynx Nasopharynx

carcinomacarcinoma

SubmaxSubmaxillaryillary and submental and submental

Oral and dental iOral and dental infectionsnfections AcAcute lymphadenitisute lymphadenitis

OccipitalOccipital

Pediculosis capitis Pediculosis capitis Tinea capitis Tinea capitis Secondary to local skin infectionsSecondary to local skin infections Rubella Rubella

PreauricularPreauricular

Local skin infectionsLocal skin infections chronic ophtalmic infectionschronic ophtalmic infections Cat-scratch diseaseCat-scratch disease

MediastinalMediastinal

ALL ALL LymphomaLymphoma SarSarkkoidosisoidosis Cystic fibrosis Cystic fibrosis TbTb Histoplasmosis Histoplasmosis CoccidiomycosisCoccidiomycosis

SupraclavicularSupraclavicular

Lymphoma Lymphoma TbTb Histoplasmosis Histoplasmosis CoccidiomycosisCoccidiomycosis

AbdominalAbdominal

Acute mesenteric adenitisAcute mesenteric adenitis Lymphoma Lymphoma

InguinalInguinal

Local iLocal infectionnfection Diaper dermatiDiaper dermatitistis Insect biteInsect bite Syphilis Syphilis LenfLenfogranuloma venerumogranuloma venerum

Approach to a patient with Approach to a patient with LAPLAP

criteria for LAP differs in pediatric age criteria for LAP differs in pediatric age group.group.

small, hard, a few mm in diameter small, hard, a few mm in diameter bilateral ant. cervical bilateral ant. cervical Axillary Axillary Inguinal Inguinal Occipital Occipital

< 2 cm.

NormalNormal < 1 cm.

< 1.5 cm.

LAP in newborn is always abnormalLAP in newborn is always abnormal Lymph nodes >10 mm are considered Lymph nodes >10 mm are considered

enlargedenlarged Epitrochlear Epitrochlear Inguinal Inguinal Posterior auricular, Posterior auricular,

epitrochlear and supraclavicular epitrochlear and supraclavicular

even 5 mm.

> 15 mm. AbnormalAbnormal

History and PEHistory and PE

History: History: DurationDuration Accompanying condition: eg: contact with Accompanying condition: eg: contact with

cats,rodent bite, tick bite, tonsillitis, skin lesions cats,rodent bite, tick bite, tonsillitis, skin lesions etc…etc…

Symptoms (fever, weight loss, night sweats)Symptoms (fever, weight loss, night sweats) Medications: fenitoin, Medications: fenitoin,

cephalosporins,sulphonamids…cephalosporins,sulphonamids… Travel historyTravel history

Physical examination: Physical examination: Localization:Localization:

tonsillar and inguinal lymph nodes: secondary to tonsillar and inguinal lymph nodes: secondary to localized infectionslocalized infections

Supraclavicular (SC) and axillary lymph nodes Supraclavicular (SC) and axillary lymph nodes (even if<0.5 cm. ) warrant further investigation(even if<0.5 cm. ) warrant further investigation

left SC: intraabdominal malignancy right SC: thoracic malignancythoracic malignancy

sizesize:: character:character:

hard,rubbery ones without tenderness and redness hard,rubbery ones without tenderness and redness suggest malignancy. Occasionally rapid growing suggest malignancy. Occasionally rapid growing malignant lymph node may be tendermalignant lymph node may be tender

Warm, tender and fluctuant lymph nodes suggest Warm, tender and fluctuant lymph nodes suggest infection or inflammation (lymphadenitis)infection or inflammation (lymphadenitis)

SymptomsSymptoms: : Localized painLocalized pain tendernesstenderness rednessredness

Dysphagia and respiratory difficulty occur Dysphagia and respiratory difficulty occur as a result of abscess formation of the as a result of abscess formation of the retropharyngeal nodes.retropharyngeal nodes.

cyanosis, dyspnea, stridor, cough, fascial cyanosis, dyspnea, stridor, cough, fascial edema suggest mediastinal LAPedema suggest mediastinal LAP

Abdominal pain suggests mesenteric and Abdominal pain suggests mesenteric and retroperitoneal LAPretroperitoneal LAP

Work-up for localized or generalized LAPWork-up for localized or generalized LAP

Thorough history of infection, contact with rodents Thorough history of infection, contact with rodents or cats and systemic complaintsor cats and systemic complaints

Physical examination for evidence of Physical examination for evidence of hematologic disease, such as hematologic disease, such as hepatosplenomegalyhepatosplenomegaly and petechiae) and petechiae)

Blood count and, ESRBlood count and, ESR Skin tests (Tb, Cat scratch disease, fungal Skin tests (Tb, Cat scratch disease, fungal

infections)infections) Cultures (from the regional lesions Cultures (from the regional lesions throat etc. throat etc. Serologic tests (Toxoplazmozis, Serologic tests (Toxoplazmozis,

CMV,EBV,HIV..etc)CMV,EBV,HIV..etc)

Chest radiograph and CT scan (if necessary); abdominal Chest radiograph and CT scan (if necessary); abdominal

sonogram and CT, if indicatedsonogram and CT, if indicated Ultrasonography is useful in an acute setting in Ultrasonography is useful in an acute setting in assessing assessing

whether a swelling is nodal inwhether a swelling is nodal in origin, an infected cyst or other origin, an infected cyst or other soft tissue mass. It may detect an abscess requiringsoft tissue mass. It may detect an abscess requiring drainage drainage

Lymph node aspiration and culture; helpful in isolating the Lymph node aspiration and culture; helpful in isolating the causative organism andcausative organism and deciding on an appropriate antibiotic deciding on an appropriate antibiotic when infection is the cause of thewhen infection is the cause of the lymphadenopathy lymphadenopathy

Fine needle aspiration; may yield a definite or preliminary Fine needle aspiration; may yield a definite or preliminary cytologic diagnosis andoccasionally obviate the need for cytologic diagnosis andoccasionally obviate the need for lymph node biopsy; it provides limited material in thelymph node biopsy; it provides limited material in the event event flow cytometry is required and negative results cannot rule out flow cytometry is required and negative results cannot rule out a malignancya malignancy because the sample may be inadequatebecause the sample may be inadequate

Bone marrow examination if leukemia or lymphoma is Bone marrow examination if leukemia or lymphoma is suspectedsuspected

Lymph node biopsyLymph node biopsy

Indications for lymph node biopsyIndications for lymph node biopsy

Lymph node biopsy is indicated if:Lymph node biopsy is indicated if:

• • Initial physical examination and history Initial physical examination and history suggest malignancysuggest malignancy

• • Lymph node size is greater than 2.5 cm in Lymph node size is greater than 2.5 cm in absence of signs of infectionabsence of signs of infection

• • Lymph node persists or enlargesLymph node persists or enlarges

• • Appropriate antibiotics fail to shrink node Appropriate antibiotics fail to shrink node within 2 weekswithin 2 weeks

• • Supraclavicular adenopathy.Supraclavicular adenopathy.

Following precautions should be observed Following precautions should be observed during Bxduring Bx

Upper cervical and inguinal areas should be avoided; lower Upper cervical and inguinal areas should be avoided; lower cervical and axillary nodescervical and axillary nodes are more likely to give reliable are more likely to give reliable informationinformation

The largest node should be biopsied, not the most accessible The largest node should be biopsied, not the most accessible one. The oncologist shouldone. The oncologist should select the node to be biopsied in select the node to be biopsied in consultation with the surgeonconsultation with the surgeon

The node should be removed intact with the capsule, not The node should be removed intact with the capsule, not piecemealpiecemeal

The lymph node should be immediately submitted to the The lymph node should be immediately submitted to the pathologist fresh or inpathologist fresh or in sufficient tissue culture medium. sufficient tissue culture medium.

The node mustThe node must not be left in strong lightnot be left in strong light it should not be wrappedit should not be wrapped in dry gauzein dry gauze.. Fresh and frozen samples should beFresh and frozen samples should be set aside for additional set aside for additional

studiesstudies

What to do with the biopsyWhat to do with the biopsy

1-culture: bacterial,viral,fungal and gram staining1-culture: bacterial,viral,fungal and gram staining2-viral studies2-viral studies3-histologic examination3-histologic examination4-light and electron microscopy4-light and electron microscopy5-immunohystochemical staning: in order to 5-immunohystochemical staning: in order to differenciate the tumor typedifferenciate the tumor type6-flow cytometry: to decide upon the type of 6-flow cytometry: to decide upon the type of leukemia or lymphomaleukemia or lymphoma7-genetic investigations7-genetic investigations