Lymphadenopathy & splenomegaly

LYMPHADENOPATHY

Ehsan Hasanpour

Lymphadenopathy :• Refers to nodes that are abnormal in :1. Size 2. Number 3. Consistency (soft ,firm ,rubbery ,hard

matted ,tender ,movable or fixed)• Soft ,flat ,submandibular nodes (<1cm)are often palpable in

healthy children and young adult ; healthy adults may have palpable inguinal nodes of up to 2cm

Lymphadenopathy :

• Generalized lymphadenopathy (enlargement of > 3 noncontiguous node regions) is often caused by systemic disease

• Localized (regional) lymphadenopathy is most frequently the result of infection in the involved node and/or its drainage area

Generalized lymphadenopathy :

• G L is frequently associated with nonmalignant disorders such as :

Infection : mononucleosis (EBV or CMV , toxoplasmosis, AIDS, other viral infections)

Immunologic disease : SLE , RA , juvenile RA , shugrens , serum sickness

Malignant lymphoma : AML , CML , ALL , CLL

Localized lymphadenopathy :

Viral bacterial malignancy Endocrine Lipid storage D

Others

EBVCMVHBV

HSV-6Varicella

zosterRubellaMeasles

AdenovirusHIV

HSV-8others

StreptococciSataphilococBrucellosis

TuberculosisTularemiaChancroid

SyphilisDiphtheria

others

Hodgkin’sNon-

Hodgkin’sHairy cell leukemia

Amyloidosismetastatic

hyperthyroidism

Gaucher’sFabry

tangier

SarcoidosisCastleman’s

Disease………

Regional adenopathy : Occipital adenopathy → infection of the

scalp Preauricular adenopathy → conjuctival

infections & cat-scratch Disease(Bartonella henselae)

Neck adenopathy → mostly benign ,upper respiratory infections ,oral & dental lesions ,EBV & CMV & other viral D

Supraclavicular & scalene nodes → mostly abnormal , Lymphomas ,others cancers(metastasis from lung , breast , testis or ovarian cancers) or infections( tuberculosis , toxoplasmosis & … ) or sarcoidosis

Regional adenopathy :

Inguinal adenopathy → infections or trauma of lower E , STD , syphilis , Genital herpes or chancroid , metastatic cancers

Axillary adenopathy → injuries , localized infection ,melanoma ,lymphoma , breast cancer

Virchow’s node :

Enlarged left supraclavicular node infiltrated with Metastatic cancer from GI primary

Lab investigation :

• The most common are CBCPBSThroat culture Chest X-rayMonospot test (R/O EBV) Lymph node biopsy

Spleen : • The spleen is a reticuloendothelial organ

that is attached to the stomach via the gastrolienal ligament and to the kidney via the lienorenal ligament.

• It abuts ribs 9-12 and its normal weights is 150 g and is approximately 13 cm in craniocaudal length.

• Usually not palpable , however ,an enlarged or palpable spleen isn’t necessarily of the clinical significance.

Function of spleen :

I. Removal of the abnormal red blood cell(RBCs)II. Synthesis of antibodies in the white pulp ,properdin ,tuftsinIII. Removal of antibody-coated bacteria and antibody-coated

blood cells from the circulationAdaptive functions :IV. Clearance of bacteria and particulates from the bloodV. The generation of immune responses to certain pathogensVI. Extramedullary hematopoiesis in certain disease

Splenomegaly :

• The most common symptoms : pain ,heavy sensation in the LUQ & early satiety.

On examination

• The major physical sign : palpable spleen (middleton maneuver)• temprature• Signs of cirrhosis(e.g jaundice,telangiectasias ,caput

medusa ,ascites)• Heart mur mur (endocarditis , congestive heart failure )• Petechiae ( any cause of thrombocytopenia )• Percussion for splenic dullness → Nixon ,Castell ,Barkun • Techniques : radionuclide scan ,CT ,MRI or ultrasonography

Splenomegaly :

1. Hyperplasia or hypertrophy (↑ splenic functions)

2. Passive congestion (↓ blood flow)

3. Infiltrative disease

Enlargement due to increased demand for splenic functions

Removing of defective

erythrocytes

Response to infection

Disordered immunoregulation

Extramedullary hematopoiesis

SpherocytosisEarly sickle cell

anemiaOvalocytosis

Thalassemia majorHemoglobinopathies

PNH

AIDSViral hepatitis

CMVSubacute bacterial

endocarditisBacterial septicemia

Splenic abscessTB

HistoplasmosisCongenital syphilis

Malaria

RASLE

Collagen vascular DSerum sickness

Immune hemolytic anemiaImmune

thrombocytopeniasSarcoidosis

Drug reactions

MyelofibrosisMarrow damage by

toxins ,radiationMarrow infiltration

by tumors ,leukemias,

gaucher’s D

Enlargement due to abnormal splenic or portal blood flow

CirrhosisHepatic vein obstructionPortal vein obstructionSplenic vein obstruction

Splenic artery aneurysmHepatic schistosomiasisCongestive heart failurePortal hypertension

Infiltration of the spleenIntracellular or extracellular

depositionsBenign and malignant cellular

infiltrationsAmyloidosisGaucher’s D

Niemann-pick DTangier D

HyperlipidemiasHurler’s syndrome

LeukemiaLymphomaHodgkin’s D

Myleoproliferative SAngiosarcomas

Metastatic tumorsHamartomashemangioma

Massive splenomegaly :• More than 8 cm below the left costal margin• Has drained weight of >1000 g

Lab assessment :

CBC diffPBS LFTs Rheumatoid factorUrine culture

Splenectomy : Diagnostic purpose Splenic rupture ( trauma or iatrogenic ) Malignancy Hereditary spherocytosis (at the age of 4 years) Staging for hodgkin’s disease Splenic abcess Pyruvate kinase deficiency If other treatment fails with :

– thrombotic thrombocytopenic purpura(TTP)– Autoimmune hemolytic anemia

Splenectomy as palliative measure only :– angiosarcoma– sickle cell crisis

Post splenectomy care :

Pneumococcal immunization Reimmunisation every 5 years

Haemophilus influenza type B (HIB) vaccine Meningococcal group C vaccine Meningococcal group A vaccine Influenza vaccine yearly

Life-long prophylactic antibiotics aren’t recommended (because of resistant)