Is it Just a Swollen Node?

Is it Just a Swollen Node?
Michael B. Harris, MD
Co-Director, Institute for Pediatric Cancer and
Blood Disorders
May 21, 2015
HILTON HEAD ISLAND, SC
Disclainer
• I am a consultant for and member of the Jazz
Pharmaceutical Company’s speaker’s bureau
• I will not discuss any Jazz Pharmaceutical
products in this lecture
Is it Lymphadenopathy?
“Mr. Justice, you will know it when you
see it”
Alan Novak, SC clerk
“…I know it when I see it”
Justice Potter Stewart
Cervical
adenopathy
Submental
Supraclavicular
Major Lymphoid Organs
and Tissues
Lymphocytes formed
from CD34
hematopoietic stem
cells and undergoes
maturation
Lymphocytes
are activated
The Lymph System
Cells that occupy a lymph node
 Lymphocytes
 B-cells:
follicles and perifollicular
region of lymph node
 T-Cells: interfollicular and
paracortical region of lymph node
 Macrophages
 Dendritic
cells
What causes the enlargement of a
lymph node
“Enlargement of lymph nodes results from
antigen stimulated proliferation of lymphocytes
and other cells intrinsic to the lymph node or
from infiltration of the node by extrinsic cells
such as polymorphonuclear leukocytes or
metastatic cells.”
Reiter & Ferrando, chapter 13; Oncology of infancy and Childhood;
Orkin et al editors.
Pathogenesis of lymphadenopathy
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Pathogen enters lymph node via afferent lymphatics
Dendritic cells and macrophages process the pathogen
Degraded portions of pathogen is presented to T-cells
T-cell releases chemokines which attract B-cells
B-cells proliferate and release immunoglobulins
The following occurs: cellular hyperplasia, leukocyte
infiltration, tissue edema, vasodilatation, capillary leak and
capsular distension
A highly schematic view of the lymph node structure.
Ramon Roozendaal et al. Int. Immunol. 2008;20:1483-1487
© The Japanese Society for Immunology. 2008. All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org
Non-lymph node lymphoid tissue
Stranford; Frontiers in Immunology, 2012
Size criteria of lymphadenopathy
• Physical exam
– Cervical and axillary >1cm
– Inguinal >1.5 cm
– Epitrochlear >0.5 cm
• Radiologic criteria (measuring the short axis)
– Mediastinal ≥0.8-1 cm
– Subcarinal ≥1.5 cm
– Abdominal/pelvic ≥0.8 cm
Differential of lymphadenopathy
• Infection (bacterial, viral, fungal, protozoan)
• Vaccine induced
• Autoimmune (JIA, SLE, serum sickness,
autoimmune hemolytic anemia,)
• Storage disease (Nieman-Pick, Gaucher’s)
• Drug reactions (ex. phenytoin, penicillin and
other antibiotics, aspirin, allopurinol)
• Miscellaneous (Kawasaki, sarcoidosis, cat-scratch
fever)
• And…
Modified from Reiter & Ferrando, chapter 13; Oncology of infancy
and Childhood; Orkin et al editors.
Differential of lymphadenopathy
• Lymphoproliferative disorders
– Histiocytoses: Langerhans cell histiocytosis,
malignant histiocytosis, sinus histiocytosis with
massive lymphadenopathy (Rosai-Dorfman)
– Atypical (Castleman’s disease)
– Dysregulation of lymphocyte proliferation
(Autoimmune lymphoproliferative syndrome)
• Malignancy (Lymphoma, leukemia, metastatic solid
tumors)
Modified from Reiter & Ferrando, chapter 13; Oncology of infancy
and Childhood; Orkin et al editors.
Common infectious causes of
Lymphadenitis
• Acute, bilateral lymphadenitis
– Viral upper respiratory infections
– Streptococcus pyogenes pharyngitis
– Varicella zoster virus, herpes simplex virus
– Rubella, rubeola
• Acute unilateral lymphadenits
– Staphyloccus aureus
– Streptococcus pyogenes
without pharyngitis
Common infectious causes of
Lymphadenitis
• Chronic bilateral lymphadenitis
– Epstein-Barr virus
– Cytomegalovirus
– Toxoplasmosis gondii
– Human immunodeficiency virus
• Chronic unilateral lymphadenitis
– Nontuberculous mycobacteria, mycobacterium
tuberculosis
– Bartonella Hensley
Common masses confused with
lymphadenopathy
• Thyroglossal duct cyst
• Dermoid cyst
• Branchial cleft cyst
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Laryngocele
Hemangioma
Cystic hygroma
Cervical ribs
Mumps
• Moves with tongue protrusion
and is midline
• Midline and often calcified
• Smooth and flutulant along
SCM border
• Enlarges with Valsalva
• Mass is present at birth
• Transilluminates, compressible
• Bilateral, hard and immobile
• Mass palpated superior to jaw
line, not just inferior to it
Adapted from Coughlin A, et al; online from resident presentation at University of
Texas Medical Branch, September 2009
History and physical exam
History
Duration – >2-4 weeks
Painless or painful swelling
Waxing and waning LN size
Pet/animal contact, travel
History of infection,
vaccinations, medications,
systemic diseases, bone
and joint pain
• Associated symptoms
(fever duration/pattern,
weight loss, night sweats,
fatigue)
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Physical exam
• Sickly or well appearing
• Evidence of infection in area
drained by LN (ex. cat scratch)
• Size and distribution
(supraclav)
• Erythematous
• Tender vs non-tender
• Warm vs body temperature
• Consistency, matted, fixed or
movable
• HSM
Workup
• Suppurative (erythema, extreme tenderness,
warmth, contiguous lymph nodes)
– If fluctuant: Aspirate for cultures, gram stain
– If not fluctuant: skin tests, chest x-ray;
FNA/biopsy if these tests not diagnostic
• Not suppurative
– Local infection present
• Culture, serology
• Treat appropriately (clinical impression is key and at
times you may use empiric antibiotics)
Workup
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CBC, ESR, Chem with LDH and uric acid
Chest X-ray (especially for supraclavicular LN)
Bone marrow aspirate and biopsy
Fine needle aspiration of LN
Biopsy of LN
CT/MRI
PET scan
Workup (non suppurative LN, no local
infection)
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LN Biopsy ± BMA
Abnormal CBC (blasts,
cytopenia)
Abnormal chest x-ray
Supraclavicular LN
Rapidly enlarging or fixed
Weight loss, night sweats
Prolonged fever (usually
greater than 3 days)
Serology, skin tests, FNA, culture
• Normal CBC (can have
elevated WBC with shift)
• Normal chest x-ray
• Not supraclavicular
• Not rapidly enlarging or fixed
• No weight loss or night
sweats
• No prolonged fever
Case report
18 month old male infant
Swelling right angle of jaw for 4-5 days
Afebrile, no recent illnesses, no bone or joint pain or swelling
No one sick at home and no travel history, pet or animal exposure
Physical exam: two to three 2 cm non tender, submandibular
lymph nodes
• Rest of physical examination normal
• Treated with the following over 17 days: amoxicillin (swelling got
worse), amoxcillin/clavulanate and azithromycin
• No improvement in neck swelling, did not develop fever
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McCullogh R; Hospital Pediatrics, 2011
Case report: does this boy have typical
bacterial lymphadenitis or something
else?
• Initial empiric treatment should be based on
local sensitivity reports
– Most common bacteria
• Methicillin sensitive staphylococcus aureus
• Methicillin resistant staphylococcus aureus
• Group A beta-hemolytic streptococcus
• At presentation patient had no fever and
lymph nodes were non-tender suggesting a
different cause of the lymphadenopathy
McCullogh R; Hospital Pediatrics, 2011
Case report (continued)
• One week later he developed fever and the
neck mass was warm, tender, fluctuant and
erythematous
McCullogh R; Hospital Pediatrics, 2011
Case Report (continued)
• Ultrasound = submandibular lymph nodes
with air/fluid levels
• Admitted for surgical drainage
• Negative for Bartonella henselae,
Toxoplasma gondii
• Positive for Mycobacterium avium complex
Thank You