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LYMPHADENOPATHY &LYMPHADENOPATHY &SPLENOMEGALYSPLENOMEGALY
Martin H. Ellis MDMartin H. Ellis MD
Meir HospitalMeir Hospital
CLINICAL ANATOMY OF CLINICAL ANATOMY OF THE LYMPH NODESTHE LYMPH NODES
Head & Neck – Head & Neck – occipital, postauricular, occipital, postauricular, preauricular, anterior cervical chain, preauricular, anterior cervical chain, posterior cervical chain, submandibular, posterior cervical chain, submandibular, submental, Waldeyer’s ringsubmental, Waldeyer’s ring
Clavicular – supra and infraClavicular – supra and infra Axillary – Axillary – lateral, medial, posterior, apicallateral, medial, posterior, apical EpitrochlearEpitrochlear InguinalInguinal FemoralFemoral
RADIOLOGICAL ANATOMY RADIOLOGICAL ANATOMY OF LYMPH NODESOF LYMPH NODES
MediastinalMediastinal PerihilarPerihilar RetroperitonealRetroperitoneal MesentericMesenteric IliacIliac
DIAGNOSISDIAGNOSIS
History & Physical diagnosisHistory & Physical diagnosis Laboratory testingLaboratory testing CT scanningCT scanning MRIMRI Isotope scanningIsotope scanning PET-CT scanningPET-CT scanning Histologic diagnosisHistologic diagnosis
APPROACH TO APPROACH TO DIAGNOSISDIAGNOSIS
Localized vs. generalized Localized vs. generalized (including splenomegaly)(including splenomegaly)
HistoryHistory Physical examPhysical exam Special investigationsSpecial investigations
CHARACTERISTICS OF CHARACTERISTICS OF ENLARGED NODESENLARGED NODES SizeSize
– < 1cm=normal< 1cm=normal Pain/TendernessPain/Tenderness
– inflammation/rapid growthinflammation/rapid growth ConsistencyConsistency
– stony, rubbery, firm, soft, fluctuantstony, rubbery, firm, soft, fluctuant MattingMatting
– a group of nodes that seem joineda group of nodes that seem joined MobilityMobility LocationLocation
DIFFERENTIAL DIFFERENTIAL DIAGNOSISDIAGNOSIS
CongenitalCongenital AcquiredAcquired
– Infectious – Infectious – bacterial,viral,fungal,parasitic,mycobacterialbacterial,viral,fungal,parasitic,mycobacterial
– Inflammatory – Inflammatory – autoimmune, allergic, vasculiticautoimmune, allergic, vasculitic– Neoplastic – Neoplastic – benign, malignant (primary,secondary)benign, malignant (primary,secondary)– Toxic & Metabolic – Toxic & Metabolic – storage diseases, hyperthyroidismstorage diseases, hyperthyroidism– DrugDrug – hydantoin, gold – hydantoin, gold– TraumaticTraumatic– Idiopathic – Idiopathic – sarcoidosis, Castleman diseasesarcoidosis, Castleman disease– Iatrogenic – Iatrogenic – silicone implantssilicone implants
SITE-DISEASE SITE-DISEASE ASSOCIATIONSASSOCIATIONS
Occipital – rubellaOccipital – rubella Supraclavicular – TB (scrofula), lung ca, Supraclavicular – TB (scrofula), lung ca,
gastric ca (Virchow node- Trousseau gastric ca (Virchow node- Trousseau sign)sign)
Axillary – breast caAxillary – breast ca Inguinal – STDsInguinal – STDs Umbilical – ovarian ca (Sister Joseph’s Umbilical – ovarian ca (Sister Joseph’s
node)node)
Hx / PE
DIAGNOSTICeg local infection,tumor
SUGGESTIVEeg mono,HIV,lymphoma
UNEXPLAINED
TREAT CONDITION
SPECIFIC TESTING
POSITIVE
LOCALIZEDGENERALIZED
Review epidemiologyReview medicationsPOSITIVE
DIAGNOSTIC
POSITIVE
No serious illness apparent
Observe 3-4 weeks
BiopsyResolved
Serious illnessapparent
Biopsy
MONONUCLEOSIS SEROLOGYPPD,HIV,HBV,CXR
NEGATIVE
BIOPSY ABNORMAL NODE
SPLENOMEGALY: SPLENOMEGALY: DIAGNOSISDIAGNOSIS
History & Physical diagnosisHistory & Physical diagnosis Laboratory testingLaboratory testing CT scanningCT scanning MRIMRI Isotope scanningIsotope scanning PET-CT scanningPET-CT scanning Histologic diagnosisHistologic diagnosis
DIFFERENTIAL DIFFERENTIAL DIAGNOSISDIAGNOSIS
CongenitalCongenital AcquiredAcquired
– Infectious – Infectious – bacterial,viral,fungal,parasitic,mycobacterialbacterial,viral,fungal,parasitic,mycobacterial
– Inflammatory – Inflammatory – autoimmune (SLE, Felty syndrome)autoimmune (SLE, Felty syndrome)– Neoplastic – Neoplastic – benign, malignant (primary,secondary)benign, malignant (primary,secondary)– Toxic & Metabolic - Toxic & Metabolic - (storage diseases eg Gaucher)(storage diseases eg Gaucher)– Congestive splenomegaly – Congestive splenomegaly – portal hypertensionportal hypertension– ““Work” hyperplasiaWork” hyperplasia- chronic hemolytic anemias- chronic hemolytic anemias
MASSIVE MASSIVE SPLENOMEGALYSPLENOMEGALY TumorsTumors
– Lymphoma, myeloproliferative Lymphoma, myeloproliferative disorders, Hairy cell leukemiadisorders, Hairy cell leukemia
InfectionsInfections– Kala-azar (trypanosomiasis)Kala-azar (trypanosomiasis)
Portal hypertensionPortal hypertension Gaucher diseaseGaucher disease
Approach to diagnosis-Approach to diagnosis-splenomegalysplenomegaly Known illnesses Known illnesses
– eg eg lymphoma, SLElymphoma, SLE Current clinical contextCurrent clinical context
– Fever, Fever, recentrecent travel, murmers travel, murmers Imaging studiesImaging studies
– SizeSize, focal , focal lesionslesions Histologic diagnosis Histologic diagnosis
– Splenectomy, ?splenic biopsySplenectomy, ?splenic biopsy