Clinical Presentation

Lymphadenopathy may be a presenting sign or symptom or an incidental finding. Up to two thirds of patients have non-specific causes or upper respiratory illness. Patients may present with sore throat, cough, fever, night sweats and fatigue or weight loss. There are many diseases associated with lymphadenopathy. The major categories are listed in Table 44.1.

B-cells CD20+

Figure 44.2. Normal immunoarchitecture of lymph node.

B-cells CD20+

Figure 44.2. Normal immunoarchitecture of lymph node.

Pre Pre B cell

Pre B cell

Immature B cell

Mature B cell

BCL-e

Folicle centre B cell

Immunoblast

Prothymocyte

Plasma cell

Prothymocyte

Pre Pre B cell

Pre B cell

Immature B cell

Mature B cell

BCL-e

Folicle centre B cell

Immunoblast

Plasma cell

Figure 44.3. Development of B and T lymphocytes.

Table 44.1. Causes of lymphadenopathy

Infectious Diseases

Viral: Infectious mononucleosis, hepatitis, herpes simplex, HIV, measles, Varicella zoster, rubella.

Bacterial: Streptococci, Brucellosis, Tuberculosis, other mycobacterial infection, plague, primary and secondary syphilis.

Fungal: Histoplasmosis, cryptococcosis.

Chlamydia: Lymphogranuloma venereum.

Parasitic: Toxoplasmosis, Leishmaniasis.

Rickettsial: Rickettsial pox, scrub typhus.

Immunologic Disorders

Rheumatoid arthritis, lupus erythematosus, dermatomyositis, Sjogren's syndrome, primary biliary cirrhosis Drug hypersensitivity: Diphenylhydantoin, hydralazine, allopurinol, gold, carbamazepine. Graft versus host disease.

Malignancy

Haematological Metastasis: from various sites.

Lipid Storage Disorders

Nieman Pick's, Gaucher's.

Endocrine Diseases

Hyperthyroidism.

Others

Castleman's disease, sarcoidosis, dermatopathic lymphadenitis, Kikuchi's disease, sinus histiocytosis with massive lymphadenopathy, inflammatory pseudotumour.

Pain in a lymph node is usually secondary to inflammation. However, rapid enlargement and pain may be present in lymphomas and leukaemias. Lymphadenopathy can be localised or generalised. The site of enlargement may provide a clue to the cause. Some of the common sites of lymphadenopathy and causes of enlargement are listed in Table 44.2.

Small size (< 1 cm diameter) usually indicates a benign lymph node.

Malignant lymphoma: large, discrete, symetric, mobile, rubbery, non-tender lymph nodes.

Metastatic carcinoma: hard, non-tender lymph nodes fixed to surrounding tissues.

Patients with lymphadenopathy may have splenomegaly as seen in chronic lymphocytic leukaemia, lupus erythematosus, toxoplasmosis and various haematological disorders.

Non-superficial lymphadenopathy: thoracic or abdominal. Thoracic lymph nodes may be secondary to lung diseases and identified on routine chest X-ray. Other symptoms are cough and wheezing from airway compression, hoarseness from recurrent laryngeal nerve involvement, dysphagia from oesophageal compression or swelling of the face due to superior vena cava compression. Abdominal/retroperitoneal lymph nodes if enlarged are usually malignant. However, tuberculosis can also cause mesenteric lymphadenopathy.

Table 44.2. Sites of lymphadenopathy and the related causes

Occipital: scalp infection. Pre-auricular: conjunctival infection.

Neck: oral, dental and respiratory infections, viral diseases, e.g., infectious mononucleosis. Malignant neck nodes: drain thyroid, head and neck, breast and lung carcinomas.

Scalene and supraclavicular (Virchow's nodes): always abnormal if enlarged as these drain lung and retroperitoneum. Causes: infection, lymphomas or other malignancies. Tuberculosis, sarcoidosis and toxoplasmosis are the commonest causes of non-neoplastic enlargement at this site.

Virchow's node: is associated with a gastrointestinal primary. Metastasis from the lung, breast, testes and ovaries may present as lymphadenopathy at this site.

Axillary: Non-neoplastic: trauma, infection of the ipsilateral upper extremity.

Neoplastic: metastasis from malignant melanoma, breast cancer or lymphoma.

Inguinal: Non-neoplastic: trauma, infection of the lower extremities or venereal diseases.

Neoplastic: metastasis from cancers of lower rectum, anal canal, genitalia and melanoma of the lower extremities.

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