Transcript A- Infections

LENFADENOPATHY
DEFINITION
abnormality of the lymph nodes in
terms of number, hardness, and
volume
LAP

Generalized
LAP:
two or more
seperate lymph
node group are
effected.

Localized LAP:
one or more
lymph nodes in
the same region
are effected
Epidemiology

Rece is not a major criteria.
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Sex: M/F=1
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Age: most frequent in younger children,
less frequent in newborn.
Pathophsiology
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Increase in the number of benign lymphocytes and
macrophages in the process of response to antigens
Infiltration of the lymph nodes with the inflammatory
cells during infection
Infiltration of the lymph nodes with metastatic
malignant cells
In situ proliferation of lymphocytes and macrophages
Infiltration of the lymph nodes with metabolite-laden
macrophages during storage diseases
I. Generalized Lenfadenopahy
A- Infection
B- Neoplastic ve proliferative disorders
C- Storage diseases
D- Autoimmune disorders and
hypersensitivity reactions
A- Infections
1- Viral:
- Generalized upper respiratort tract
infections
- Infectious mononucleosis
- CMV
- AIDS
- chickenpox
- measles
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A- Infections
2-Bacterial
- Septisemia
- Typhoid fever
- Tb
- Syphilis
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A- Infections
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3- Protozoal - Toxoplazmosis
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4- Fungal - Coccidiomycosis
B- Neoplastic and
Proliferative Disorders
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Acute leukemia
Lymphomas (Hodgkin, non-Hodgkin)
Neuroblastoma
Histiocytosis
C- Storage diseases
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Gaucher
Niemann-Pick
D- Otoimmune disorders and
Hypersensitivity reactions
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Juvenile rhomatoid arthritis (JRA)
Systemic lupus erythematosus
Drug reactions (eg: fenitoin, allopurinol)
Serum sickness
2- Localized
lymphadenopathy
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Cervical
Submaxillary and submental
Occipital
Preauricular
Mediastinal
Supraclavicular
Axillary
Abdominal
Inguinal
Cervical
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Viral URTI
IM
Rubella
Cat scratch disease
Streptococcal
pharyngitis
Acute bacterial
lymphadenitis
Toxoplasmosis
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Tb/atypical
mycobacterial
infection
Acute leukemia
Lymphoma
Neuroblastoma
Rhabdomyosarcoma
Kawasaki disease
Nasopharynx
carcinoma
Submaxillary and submental
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Oral and dental infections
Acute lymphadenitis
Occipital
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Pediculosis capitis
Tinea capitis
Secondary to local skin infections
Rubella
Preauricular
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Local skin infections
chronic ophtalmic infections
Cat-scratch disease
Mediastinal
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ALL
Lymphoma
Sarkoidosis
Cystic fibrosis
Tb
Histoplasmosis
Coccidiomycosis
Supraclavicular
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Lymphoma
Tb
Histoplasmosis
Coccidiomycosis
Abdominal
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Acute mesenteric adenitis
Lymphoma
Inguinal
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Local infection
Diaper dermatitis
Insect bite
Syphilis
Lenfogranuloma venerum
Approach to a patient with
LAP
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criteria for LAP differs in pediatric age
group.
small, hard, a few mm in diameter
< 2 cm.
bilateral ant. cervical
< 1 cm.
Axillary
Normal
< 1.5 cm.
Inguinal
Occipital
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LAP in newborn is always abnormal
Lymph nodes >10 mm are considered
enlarged
even 5 mm.
Epitrochlear
> 15 mm.
Inguinal
Abnormal
Posterior auricular,
epitrochlear and supraclavicular
History and PE
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History:
Duration
 Accompanying condition: eg: contact with
cats,rodent bite, tick bite, tonsillitis, skin lesions
etc…
 Symptoms (fever, weight loss, night sweats)
 Medications: fenitoin,
cephalosporins,sulphonamids…
 Travel history
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Physical examination:
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Localization:
tonsillar and inguinal lymph nodes: secondary to
localized infections
 Supraclavicular (SC) and axillary lymph nodes
(even if<0.5 cm. ) warrant further investigation
left SC: intraabdominal malignancy
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right SC: thoracic malignancy
size:
 character:
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hard,rubbery ones without tenderness and redness
suggest malignancy. Occasionally rapid growing
malignant lymph node may be tender
 Warm, tender and fluctuant lymph nodes suggest
infection or inflammation (lymphadenitis)
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Symptoms:
Localized pain
 tenderness
 redness
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 Dysphagia
and respiratory difficulty occur
as a result of abscess formation of the
retropharyngeal nodes.
 cyanosis, dyspnea, stridor, cough, fascial
edema suggest mediastinal LAP
 Abdominal pain suggests mesenteric and
retroperitoneal LAP
Work-up for localized or generalized LAP
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Thorough history of infection, contact with rodents
or cats and systemic complaints
Physical examination for evidence of
hematologic disease, such as
hepatosplenomegaly and petechiae)
Blood count and, ESR
Skin tests (Tb, Cat scratch disease, fungal
infections)
Cultures (from the regional lesions  throat etc.
Serologic tests (Toxoplazmozis,
CMV,EBV,HIV..etc)
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Chest radiograph and CT scan (if necessary); abdominal
sonogram and CT, if indicated
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Ultrasonography is useful in an acute setting in
assessing
whether a swelling is nodal in origin, an infected cyst or other
soft tissue mass. It may detect an abscess requiring drainage
Lymph node aspiration and culture; helpful in isolating the
causative organism and deciding on an appropriate antibiotic
when infection is the cause of the lymphadenopathy
Fine needle aspiration; may yield a definite or preliminary
cytologic diagnosis andoccasionally obviate the need for
lymph node biopsy; it provides limited material in the event
flow cytometry is required and negative results cannot rule out
a malignancy because the sample may be inadequate
Bone marrow examination if leukemia or lymphoma is
suspected
Lymph node biopsy
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Indications for lymph node biopsy
Lymph node biopsy is indicated if:
• Initial physical examination and history
suggest malignancy
• Lymph node size is greater than 2.5 cm in
absence of signs of infection
• Lymph node persists or enlarges
• Appropriate antibiotics fail to shrink node
within 2 weeks
• Supraclavicular adenopathy.
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Following precautions should be observed
during Bx
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Upper cervical and inguinal areas should be avoided; lower
cervical and axillary nodes are more likely to give reliable
information
The largest node should be biopsied, not the most accessible
one. The oncologist should select the node to be biopsied in
consultation with the surgeon
The node should be removed intact with the capsule, not
piecemeal
The lymph node should be immediately submitted to the
pathologist fresh or in sufficient tissue culture medium.
The node must not be left in strong light
it should not be wrapped in dry gauze.
Fresh and frozen samples should be set aside for additional
studies
What to do with the biopsy
1-culture: bacterial,viral,fungal and gram staining
2-viral studies
3-histologic examination
4-light and electron microscopy
5-immunohystochemical staning: in order to
differenciate the tumor type
6-flow cytometry: to decide upon the type of
leukemia or lymphoma
7-genetic investigations