Lymphadenitis: The inflammation and/or enlargement of a lymph node.

• Most cases represent a response to benign, local, or generalized infections.

• Lymphadenitis may be generalized or affect a single node (local adenopathy) or a

localized group of nodes (regional adenopathy) and may be unilateral or bilateral.

• The onset and course of lymphadenitis may be acute, subacute, or chronic.

Pathophysiology

• Increased node size may be caused by the following:

o Multiplication of cells within the node, including lymphocytes, plasma cells,

monocytes, or histiocytes.

o Infiltration of cells from outside the node, such as malignant cells or neutrophils.

o Draining of a source of infection by lymph nodes.

• If the cause of adenopathy is not evident, consider congenital or neoplastic causes.

Causes and Clinical Presentations of Lymphadenitis

Causes

• Infections

o Acute, local one-sided, pyogenic adenitis is most common.

o Etiologic agents include group A beta-haemolytic streptococci, staphylococcal

organisms (especially staphylococcus aureus) and viruses

o Mycobacterium tuberculosis

o If inguinal adenopathy- consider sexually transmitted diseases or testicular

malignancy

o Brucellosis

o Yesinia species

o Salmonella

o Infectious mononucleosis

o Cytomegalovirus

o Toxoplasmosis

• Immunologic or connective tissue disorders

o Rheumatoid

• Primary disease of lymphoid or reticuloendothelial tissue

o Acute leukaemia

o Lymphosarcoma

o Hodgkin disease

o Non-Hodgkin lymphoma

o Non-endemic Burkitt tumour

o Immunodeficiency syndromes

Clinical Presentation

• History

o Upper respiratory symptoms, sore throat, earache, coryza, conjunctivitis, and impetigo

o Fever, irritability, and anorexia.

o Dental and or oral conditions: Submaxillary adenopathy may develop secondary to

stomatitis, dental caries, or a dental abscess.

o Acute or chronic onset

-Bilateral acute cervical adenitis is usually caused by either viral pharyngitis or

infectious mononucleosis, but could also been seen in acute HIV seroconversion.

-Chronic localized adenopathy can be attributed to a persistent regional infection.

o Skin and scalp conditions: Occipital and postauricular adenopathy may accompany

scalp infections, seborrhic dermatitis, or scalp pediculosis.

-Epitrochlear and axillary lymphadenopathy may result from infections on the

arms.

-Inguinal and femoral adenopathy may be due to infections on the lower

extremities or sexually transmitted infections in the genital region.

o Periodicity: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis

(PFAPA) syndrome usually results in adenopathy associated with the other findings

every 3-6 weeks.

• Physical examination

o Location

-Most patients with lymphadenitis exhibit small palpable cervical, axillary, and

inguinal nodes.

-Some patients have palpable suboccipital or postauricular nodes.

-Rubella and parvovirus infection is characterized by enlarged and tender posterior

auricular, posterior cervical and occipital lymph nodes.

-Atypical (environmental) mycobacterial may cause submandibular or submental

adenopathy.

-Mediastinal or infectious hilar adenopathy may occur in patients with

tuberculosis, chronic sinusitis, histoplasmosis, tularemia, infectious

mononucleosis, candidiasis, coccidioidomycosis, and bronchiectasis.

o Size: Lymph nodes that are noted to increase rapidly in size may indicate potential

malignancy.

o Shape: Confluent lymph nodes may be indicators of malignancy.

o Consistency

-Descriptors may include soft, fluctuant, firm, rubbery, or hard.

-In early stages, nodes in tuberculosis are well-demarcated, mobile, non tender, and

firm.

-If the infection remains untreated, the nodes soften, become fluctuant, and adhere

to the skin, which may be erythematous and eventually ulcerate.

-In Hodgkin disease, nodes are initially soft.

-They later become firm and rubbery.

o Fixation of lymph nodes to the skin and soft tissue may indicate malignancy.

o Tenderness

-Lymph nodes of infectious aetiology are usually tender.

-Hodgkin lymphoma may initially present as painless lymph node enlargement,

especially of the cervical and supraclavicular region.

o Overlying skin

-The overlying skin may be erythematous in infectious etiologies.

-Draining sinuses may develop in patients with tuberculosis adenopathy.

o Systemic signs

-Group B streptococcal cellulites and adenitis are characterized by sudden onset of

fever, anorexia, irritability, and submandibular swelling.

-Hepatosplenomegaly is common in patients with infectious mononucleosis.

Differential Diagnosis and Investigations of Lymphadenitis

Differential Diagnosis

• Brucellosis

• Neuroblastoma

• Chronic granulomatous disease

• Non-Hodgkin lymphoma

• Cytomegalovirus infection

• Rhabdomyosarcoma

• Salmonella infection

• Sarcoidosis

• Sickle cell anaemia

• Hodgkin’s disease

• Rheumatoid arthritis

• Tuberculosis

• Mononucleosis and Epstein-Barr virus infection

• Acute HIV or chronic HIV infections

• Syphilis

Investigations

• Laboratory studies

o Gram stain: Staining can be performed on aspirated tissue.

o Culture can be taken of aspirated tissue or specimen can be biopsied.

o Serologies are useful to confirm the diagnosis of infectious mononucleosis.

o Skin testing: Purified protein derivative testing can be helpful in confirming the

diagnosis of tuberculosis lymphadenopathy and may be suggestive of atypical

mycobacterial infection.

o Full blood picture: A high white blood count may indicate an infectious aetiology.

o Erythrocyte sedimentation rate: A high erythrocyte sedimentation rate is a nonspecific

indicator of inflammation.

o Liver function tests: These may indicate hepatic or systemic involvement.

o An elevation may occur in infectious mononucleosis.

o Usually, a blood culture test demonstrates positive results.

• Imaging studies

o Chest radiography: Radiography may be helpful in determining pulmonary

involvement or spread of lymphadenopathy to the chest.

Management and Complications of Lymphadenitis

Management

• In patients with lymphadenopathy, treatment depends on the causative agent and may

include the following:

o Antimicrobial therapy

o Chemotherapy

o Radiotherapy

o Surgical care

-Excisional biopsy: Lymphadenitis caused by atypical mycobacterial may have

improved cosmetic outcome with surgical excision.

-Aspiration

-Incision and drainage

Complications

• Cellulitis

• Suppuration

• Systemic involvement

• Internal jugular vein thrombosis

• Septic embolic phenomena

• Purulent pericarditis

Clinical Presentation and Management of TB Lymphadenitis

• In tuberculosis lymphadenitis tubercle bacilli enter the body through the tonsil of the

corresponding side.

• From there they move to the cervical lymph nodes, so the upper deep cervical nodes are

most often affected.

Clinical Presentation

• There is no generalized infection, so the cervical nodes involvement is not secondary to

tuberculosis anywhere in the body.

• This is commonly found in children and young adults. It may occur at any age.

• This incidence in the young has diminished since the introduction of BCG vaccination.

• The cervical nodes are most frequently involved followed by mediastinal, mesenteric,

axillary, and inguinal nodes according to the order of frequency.

Investigations

• Full blood picture

• Chest X- ray

• Refer for further management (biopsy, AFB and treatment)

Treatment

• Anti-tuberculosis drugs should be prescribed once the diagnosis is confirmed.

• Nutritious food (vitamin supplementation and high protein diet) are the supportive

therapies which every patient with tuberculosis of the lymph nodes should receive.

• If the lymph nodes do not respond to the drug therapy or show initial response but remain

static after that, operative removal is justified.

• If cold abscess has been formed, it is advisable to start the antituberculous therapy and to

aspirate the abscess before it ruptures with sinus formation.

• Aspiration is performed with a thick needle through the healthy skin preferably from

above.

 

References

• Das S. (2008). Concise Textbook of Surgery (5th ed.). India.

• Fraser L, Moore P & Kubba H. (2008). Atypical Mycobacterial Infection of the Head and

Neck in Children: A 5-Year Retrospective Review. Otolaryngology – Head and Neck

Surgery, 138(3):311-4.

• Friedmann A.M. (2008, February). Evaluation and Management of Lymphadenopathy in

Children. Pediatric Review, 29(2):53-60.