Transcript Slide 1

Def.:
It is an abnormal increase in size,
or altered consistency of L.N. & is a
clinical manifestation of regional or
systemic disease
& serve as an
excellent clue to the underlying
pathology and aetiology.
Causes of Localised Lymphadenopathy
1- L.N Draining a Septic Focus:
* cervical : tonsilitis, scarlet fever, scalp infection.
* periauricular: otitis media.
* axillary : infections of fingers
* inguinal : infections of lower extremities.
* popliteal : infections of heel.
2-Carcinomatous L.N. Draining a Malignant Tumour:
* hilar and scalene: bronchus.
* virchow’s: stomach
* cervical: thyroid, tongue, parotid.
Causes of Localised Lymphadenopathy(2)
3- Systemic Infections
* Viruses:
a- Viral hepatitis Rt. supraclavecular L.N
b- L.G.V. --groin (ing LN)
c- German measles (cervical LN)
* Bacteria:
a- Plague
b- T.B
* Spirochetes : (Iry $ draining chancer)
a- penis
inguinal L.N.
b- lips
submandibular L.N.
c-nipple
axillary L.N.
* Protozoa
a -Filarial infectious----- inuguinal L.N.
N.B Generalized L.N. may start as localized L.N. as in Hodgkin’s disease
Causes of Generalised Lymphadenopathy
I- Infectious
* Viruses:
a-Infectious mononucleosis
b-Cytomegalo virus (C.M.V.)
* Bacteria: a- brucellosis
b- T .B.
*Spirochetes:
(2ry $)
* Protozoa
a- kala azar
b-toxoplasmosis.
Causes of Generalised Lymphadenopathy(2)
2- Leukaemias:
(C.L.L.)
3- Lymphomas:
especially chronic lymphocytic leukamia
a- Hodgkin’s disease (H.D.)
b-Non- Hodgkin’s lymphoma (N.H.L)
4- Collagenosis: a-rheumatoid artheritis.
b- Felty’s syndrome.
c-Still's disease.
d- D.L.E.
5-Allergy:
e.g., - Serum sickness.
6- Sarcoidosis
7- Lipoidosis
8-Miscellaneous
Characters of L.N. Enlargement in Some Diseases
1- Streptococcal infection of tonsils:
* Uni or Bilateral * Tender & unmatted
*Usually submandibular but may extend to lower cervical
group.
2- Scarlet Fever
* Sore throat.
* marked enlargement of submandibular L.N.
*Other cervical L.N. (bilateral, tender, discrete, suppuration
is common).
3-Diphtheria
*Enlarged submandibular L.N. usually bilateral, tender, not
matted.
4-German Measle:
* OccipitaI L.N. enlargement are nearly always present, closely
resembles that of infectious mononucleosis.
5-Infectious Mononucleosis:
* Sore throat, Fever, sometimes headache, myalgia.
* Bilateral L.N. enlargement, firm, discrete, mobile.
* Appear first in posterior cervical area, adjacent to cervical
spines, few days later , submandibular L.N. will be enlarged
* Palatal petechiae often, are present
* Mild splenomegally in 50% of cases
*Lymphocytosis in 75% of cases with some atypical
lymphocytes.
6- T.B.:
* The chiefly affected group is upper cervical group,
generalized L.N. enlargement is exceptional.
* Unilateral or Bilateral.
* Often firm, matted, painful, may become adherent
to skin or deep structures.
* Cystic areas may occur due to caseation and later on
cold abscess formation.
* Overlying skin may break down giving T.B. ulcers
or sinuses.
7-Syphilis:
* Iry $:L.N draining a chancre
-Rocky hard, uni Or bilateral, not tender.
* 2ry $:-Generalized L.N. enlargement especially
posterior triangle of the neck or epitrochlear gp
(slightly enlarged, shotty, discrete, painless).
8- LYMPHOMATOUS L. N:
*May
be
associated
with
constitutional
symptoms.(anorexia, fever, weight loss, sweating, …..
etc).
* Pel Ebstein fever: may be observed in H.D., it is a
period of fever lasting for few days or weeks alternating
with longer or shorter apyrexial periods .
* L.N. usually discrete at start & not tender (but may
become tender during febrile periods).
* L.N. may increase in size during pyrexial periods and
decrease in size during apyrexial periods
a-H.D.:
* may be confined to one group at first esp. lower cervical
group then later on generalized L.N. enlargement.
•Glands are:
a- moderately enlarged, not tender.
b- Firm, rubbery in consistency.
c- Discrete, mobile however as a result of later
extension outside the capsule glands become matted or fixed
b-N.H .L:
*Also the cervical group is firstly affected
*Rapid rate of growth results in large number of variable
sized nodes which are hard in consistency, tend to become
fused and fixed to deep structures & may give pressure
manifestations.
9- LEUKAEMIC L. N:
*May be associated with general manifestations (fever,
malaise, anorexia, headache, Hemorhagic tendency)
a- Acute Leukaemia:
*Late, slightly or moderately enlarged
*Soft, discrete esp. cervical L.N. due to oral sepsis
*May be tender bone.
b-C.L.L:
* May affect cervica1 L.N. but mostly all superficial L.N.
are enlarged.
*The glands usually are (firm, not tender, not matted,
usually moderately enlarged, but in advanced stages may
be markedly enlarged)
c-C.M.L.:
*Rare to be manifested by L.N. enlargement.
10- CARCINOMATOUS L.N.:
*Firm, but some times hard.
*A stoney hard nodes fixed to underlying
tissues are nearly always neoplastic in
nature, however the reverse is not true.
*Carcinomatous L.N. may be freely
mobile
Presentation:
* Swelling
* Constitutional symptoms (fever, sweating, loss of wt., pruritis)
* Pressure symptoms:
- Mediastinal syndrome
- Pressure on veins → oedema
- Pressure on nerves → pain
Age:
* T.B.: usually in children and young adults.
* H.D. : any age including childhood, but its highest incidence ( )
(20-40 ys)
* N.H.L.: usually at middle age and late life.
* Acute Leuk.: any age, but highest in first 6 years of life.
History:
* of infections, drugs, or vaccinations.
Distribution:
* Localized or generalized.
* Single or multiple groups affected.
Characters mentioned before.
Other Signs:
*Fever: Leuk., H.D., N.H.L., Pel Ebstein fever.
*Jaundice : H.D.,Chronic leuk. (due to hepatic
infiltration → pressure on bile duct)
*Eye: in leuk. (infections, sub conj. Hge.,
exophthalmos.)
* Mouth, Tonsils, Parotid, Gums.
* Skin:
-pruritis, esp. H.D., N.H.L., Leuk.
- Rash in L.G.
- skin nodules in C.L.L., NHL.
- herpes zoster in H.D.
* Genitalia: chancre, chancroid, ulcer, gonorrhea
* Mediastinum & Chest : mediastinal syndrome, pleural effusion.
* Tenderness of sternum : in C.M.L.
* Bone tenderness. & Pathological fractures : in H.D. & N.H.L.
*Abdomen:
- ascitis and masses
- liver:
i- acute leuk : late & slightly enlarged.
ii-C.M.L. : firm & smooth
iii- C.L.L. : enlarged liver
- spleen : huge in C.M.L. & may be friction rub
* N.B.: in H.D.:
2/3 moderately enlarged spleen.
I /3 moderately enlarged liver.
in Sarcoidosis : hepatosplenomegaly in 1/3 of
cases
* Limbs : bone aches, swelling, joint affection.
* C.N.S:
- esp. M.D. & N.H.L.
- brain & spinal cord : Hge, meningeal infiltration,
pressure manifest.
- peripheral nerves: pain, parathesia.
- mediastinum : Horner's syndrome, or vocal cords
* For cases of genera1ised lymphadenopathy or local
L.N. enlargement without local cases:
(1) Complete clinical examinations.
(2) C.B.P. & E.S.R.
(3) Serological tests for infections mononucleosis,T.B.
toxoplasmosis, $.
(4) Plain chest X ray.
(5) Biopsy.
(6) Bone marrow aspiration if leuk. is suspected from
C.B.P.
* Biopsy should be done for enlarged L.N. of more than
one month duration and not responding to usual ttt.
* According to L.N. biopsy ?: if:
- +ve → management.
- -ve (single reactive hyperplasia) → follow
up & if persist repeat biopsy two months later.
Isolated Mediastinal L.N. Enlargement occurs
in:
- H.D. & N.H.L.
- T.B. & Sarcoidosis.
- Cancer lung or oesophagus.
Isolated Abdominal L.N. Enlargement occurs
in:
- H.D & N.H.L
- Metastasis.
Staging of Lymphoma
A-Clinical staging:
1-Detaild history esp. in systemic symptoms.
2-Clinical examination including the Waldeyer's ring &
areas of bone metastasis.
3- Adequate surgical biopsy
4- Routine lab. tests (C.B.P. & E.S.R & liver kidney
function tests & Serum Uric acid.)
5- Plain chest X ray (P.A & Lat. view)
6- Bilateral lower extremities lymphangiography.
7- Radiological examinations (G.I.T., Gastroscopy if +
ve Waldeyer's ring)
8- Abdominal Ultrasonography or C.T. Scan.
B- Pahological staging:
1- Bone narrow biopsy.
2- Staging labarotomy. (only indicated in
H.D with clinical stage I & II, if theraputic
decision will depend on the identification of
occult abdominal involvement) .
The Ann Arbor Staging Classification:Stage I
* Involvement of single L.N. region (I)
* Or single extra nodal organ or site (IE*)
Stage II.
*involvement of two or L.N region on the
same side of the diaphragm (II).
*or. localised involvement of an extranodal
organ or site will one or more L.N. regions on the same
side of the diaphragm (IIE*).
The Ann Arbor Staging Classification:Stage III
III: involvement of L.N. regions on both sides of
diaphragm.
IIIs: may be also accompanied by splenic
enlargement
IIIE* : or by localized involvement of an
extranodal site.
IIISE* : or both.
Stage IV
* Diffuse or disseminated involvement of one or
more extranodal organs with or without associated L.N.
involvement.
NB.
* Any of them is further subdivided into:
A : without systemic symptoms.
B : with systemic symptoms
* (E) means very limited extra- lymphatic
disease (both in site & extent) subjected to define
ttt by radiotherapy. e.g:
i: L.N. + adjacent bone
ii: Ant. mediastinum + sternal invasion.
iii: Mediastinal L.N. + adjacent lung
tissues.
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