Orientri n diagnosticul adenopatiilor

09 Noiembrie 2005
Ganglionii limfatici, structurai din mai multe compartimente, ambele cu funcii speciale, sunt
parte component a sistemului limfatic distribuii n tot organismul, cu un rol major n
declanarea rspunsului de autoaprare fa de corpii strini i agenii infecioi

!tructura unui ganglion limgatic"



!tructura nodului limfatic # $ase limfatice aferente 2 !inus % &oliculul, sau centrul
germinal ' (apsula 5 )ilul * $al+e to pre+ent bac,flo- . $asul limfatic eferent



/(apsula/ format din fibre de colagen i sinusurile subcapsulare, cu un coninut bogat n
macrofage care filtrea0 limfa i rein antigenele
/ 1aracorte2ul/ cu un rspuns celular specific cu formarea limfocitelor 3 antigen / specifice i
limfocite 3 de memorie
/ 4edula / cu formarea de limfocite 5 anticorp secretoare
/ (entrul germinal sau foliculii 6 formarea precursorilor celulelor anticorp secretoare i celule
5 de memorie






7intre cei apro2imati+ *00 de noduli limfatici n mod normal pot fi palpabili doar cei din
regiunea submandibular, a2ilar i ing8inal , nodulii limfatici cu dimensiunea mai mare de
# cm fiind considerai deja anormali 3ermenul de limfadenopatie definete un proces
patologic prin afectarea ganglionilor limfatici, inclu09nd diferenele legate de mrimea,
consistena sau numrul nodulilor limfatici
:imfadenopatia poate fi local, dac o singur regiune, sau generali0at atunci c9nd dou sau
mai multe regiuni sunt afectate ;n general, ntr/un procent de .5< adenopatia este locali0at
i la doar = a bolna+ilor se obser+ adenopatie generali0at


!tudiul 7utc8 estimea0 incidena anual a limfadenopatiei ine2plicabile la 0,*< n populaia
general 1re+alena malignitii dup e2amenul 8istopatologic al ganglionilor biopsiai
atinge, n unele centre, '0/*0<
1ersoanele cu +9rsta mai mare sau egal cu '0 de ani i cu adenopatie nee2plicabil pre0int
un risc pentru malignitate de '<, n contrast cu riscul de 0,'< pentru persoanele sub aceast
+9rst


>lgoritm pentru abordarea unui bolna+ cu adenopatie"


?storic@e2amen fi0ic
















































7ate epidemiologice sugesti+e

A2punere
7iagnostic
Generale"
/ pisic
/ alimente incorect preparate
/ neptur de cpu
/ tuberculo0a
/ transfu0ii de s9nge recente sau transplant
/ comportament se2ual cu risc crescut

/ droguri intra+enoase

/boala g8earelor de pisic, to2oplasmo0a
/ to2oplasmo0a
/ boala :Bme, tularemia
/ adenita tuberculoas
/ cBtomegalo+irus, )?$

/ )?$, sifilis, 8erpes simple2,
cBtomegalo+irus, 8epatita 5
/ )?$, endocardit, 8epatita 5

Ocupaionale"
/ $9ntori, fermieri
/ pescari

/ tularemia
/ erisipeloid





(9te+a caracteristici ale nodulilor limfatici care pot fi orientati+e"
/ 4rimea" normal sub # cm, dup anumii autori ganglionii epitro8leari mai mari de 0,5
cm i cei ing8inali peste #,5 cm trebuie considerai anormali :a copii nodulii limfatici peste 2
cm, radiografia toracic anormal i absena simptomatologiei infecioase sugerea0 o boal
granulomatoas C3bc, sarcoido0D sau cancer ClimfomD
/ Ganglioni grupai, aparent conectai ntre ei pot sugera o afeciune benign C3bc,
sarcoido0a, limfogranuloma +enereumD sau malign CcancereD
/ 7urere@!ensibilitate" c9nd un ganglion limfatic crete rapid n dimensiuni capsula se
afl sub tensiune i cau0ea0 durere 7e obicei durerea apare n urma procesului inflamator i
supurati+, dar poate fi i re0ultatul 8emoragiei n centrul necroti0at al unui nodul malign
1re0ena sau absena sensibilitii nu e2clude sau nu confirm malignitatea unui nodul
/ (onsistena" nodulii limfatici foarte tari de obicei sunt semnele unui cancer, de obicei
metasta0e Nodulii adereni, cu consistena gumei de ters sugerea0 limfom Nodulii moi sunt
re0ultattul unui process inflamator Nodulii supurai fluctuea0
/ :ocali0are" locali0area anatomic a adenopatiei poate fi uneori sugesti+ pentru
diagnosticul diferenial

Nodulii limfatici adiaceni regiunii mamare"




> 4uc8iul pectoral
5 Noduli limfatici a2ilari" ni+el ?
( Noduli limfatici a2ilari" ni+el ??
7 Noduli limfatici a2ilari" ni+el ???
A Noduli limfatici supracla+isculari
& Noduli limfatici mamari interni



:ocali0are
7renajul limfatic
(au0e
!ubmandibulari
:imba, glandele submandibulare, bu0ele, ca+itatea bucal, conjuncti+ele
?nfecii ale capului, g9tului, sinusurilor, scalpului, faringelui
!ubmentali
5u0e inferioare, bolta palatin, +9rful limbii, pielea feei
!indromul mononucleosis, A5$, cBtomegalo+irus, to2oplasmo0a
Eugulari
:imba, tonsilele, parotide,
&aringite, rubeola
(er+ical posterior
!calp i g9t, pielea braelor i pectoralelor, torace, nodulii a2ilari i cer+icali
3uberculo0, limfoame, cancere ale capului i g9tului
!uboccipitali
!calp i cap
?nfecii locale
1ostauriculari
4eatul auditi+ e2tern, scalpul
?nfecii locale
1reauriculari
1leoape, conjuncti+e, regiunea temporal,
(analul auditi+ e2tern
Fegiunea supracla+icular dreapt
4ediastin, plm9ni, esofag
3umori pulmonare, retroperitoneale, gastrointestinale
Fegiunea supracla+icular st9ng
3orace, abdomen
:imfoame, cancere toracice sau retroperitoneale, infecii bacteriene sau fungice
>2ilari
5rae, peretele toracic, s9nii
?nfecii, boala 0g9rieturii de pisic, limfoame, cancerul mamar, implante de silicon, brucelo0a,
melanomul
Apitroc8leari
1artea ulnar a antebraului i m9inii
?nfecii, limfoame, sarcoido0, tularemia, sifilisul secundar
?ng8inali
Organe genitale e2terne, perineul, regiunea gluteal, peretele abdominal inferior, canalul anal
?nfeciile membrelor inferioare, 5!3 C8erpes simple2, gonoreea, sifilisul, ancrul, granuloame
ing8inale, limfogranuloma +enereumD, limfoame, cancere pel+iene




(au0ele limfadenopatiilor"

(ategorii
(ondiii
5oli infecioase
$irale" A5$, (4$, 8epatite +irale, )?$, 8erpes simple2, +aricella 6 0oster +irus, rubeola,
rujeola, ,eratoconjuncti+ita
5acteriene" streptocoi, stafilococi, boala 0g9rieturii de pisic, sifilis, tularemia, brucelo0,
tuberculo0a, micobacterii atipice, difteria, lepra
&ungice" 8istoplasmo0a, coccidioidomico0a, para/
(lamidii" limfogranuloma +enereum, tra8oma
1roto0oare" to2oplasmo0a, leis8manio0a, tripanosomia0a
Nematode" filaria0a
Fic,ettsiile
5oli imunologice
/>rtrita reumatoid
/:upusul eritematos sistemic
/5oala mi2t de esut conjuncti+
/7ermatomio0ita
/ !indromul !jogren
/ Feacii de 8ipersensibilitate la medicamente" >lopurinol, >tenolol, (aptopril,
(arbama0epina, cefalosporinele, aurul, )idrala0ina, 1enicilinele, &enitoina, 1rimidona,
1rimetamina, (8inidina, !ulfonamidele, !ulindacul, 7ifenil8idantoina, etc,
/ :imfadenopatia angio/imunoblastic
/ >sociat cu implantele din silicon
/ Feacia grefa contra ga0d
/ (iro0a biliar primiti+
(ancere
/ 5oala neoplasic primar a ganglionilor limfatici Climfoame non/)odg,in, boala )odg,in,
etc
/ 1roces neopla0ic secundar al nodulilor Cleucemiile limfatice acute i cornice, :eucemiile
mieloide, mielofibro0a cu 8ematopoie0 e2tramedularD
/ 4etasta0ele canceroase

5oli endocrine
)ipertioroidismul
3iroidita )us8imoto
?nsuficiena adreno/genital
3e0auri0mo0e
5oala Gausc8er
5oala Niemann/1ic,
5oala &aubrB
>lte boli
!arcoido0a, amiloido0a, limfadenita dermatopoietic, 5oala (astleman C8iperpla0ia
angiofolicular a ganglionilorD, boala Gi,uc8i Climfadenita 8istiocitar necroti0ant, Ga-asa,i
Csindromul limfonodular mucocutanatD, febra mediterian, 8ipertigliceridemia se+er,
8istiocito0a H, etc







1re+alena cau0elor comune a limfadenopatiilor


(au0a
1re+alena relati+ n populaia general
>denopatii nespecifice, cu resorbie spontan
29/*'<
3raume locale, mucturi, plgi tiate
%2<
?nfecii acute ale cilor respiratorii superioare
#I<
4ononucleo0a infecioas
2/#0<
>lte infecii C3bc, 53!, tularemia, boala g8earelor de pisicD
!c0ut
4aligniti
0,I/#,#<, '< la adulii peste '0 de ani


!emne clinice sugesti+e"


&ebr
4ononucleo0a, tuberculo0a, limfoame, 8ipersensibilitate la medicamente, brucelo0a, 8erpes
0oster, 8epatita 5, (4$, )?$, A5$, 8erpes genital, boala :Bme
!cdere ponderal
(ancere, tuberculo0
&atigabilitate
3uberculo0a, neoplasme, A5$, mononucleo0a
3rasnpiraii nocturne
3uberculo0a, neoplasme
>rtralgii
Neopla0ii, 8ipersensibilitate medicamentoas
Fas8 cutanat generali0at
8ipersensibilitate medicamentoas, )?$, mononucleo0a, 8epatita 5
Fas8 cutanat sugesti+
Fubeola, rujeola, b :Bme, :A!, 8erpes 0oster
1apule
)erpesul genital, ancrul, sifilisul primar, tularemia
!tare general alterat
)erpes 0oster, )?$, (4$, A5$, 8ipersensibilitate medicamentoas, neoplasii
)emopti0ie
4etasta0e
3use
4etasta0e, mononuclo0a , sarcoido0a, tuberculo0a, limfoame
7isfagie
4etasta0e, mononuclo0a , sarcoido0a, tuberculo0a, limfoame
&aringit
?nfecii streptococice, A5$, (4$, gonorea
?nflamaie genital
5!3" 8erpes genital, sifilis, ancrul limfogranuloma +enereum, granuloma inguinale,
!plenomegalie
!indromul de mononucleo0, to2oplasmo0, limfoame, leucemii, !:A, sarcoido0
)ematurie
4etasta0e
7ureri abdominale
4etasta0e
!caune cu s9nge
4etasta0e


7iagnosticul diferenial al adenopatiilor la bolna+ii cu simptome generale

!imptome
>feciunea
A2aminri recomandate
/ :imfoamele indolente se pre0int de obicei cu limfadenopatie generali0at sau locali0at, de
consisten mai ferm, cu splenomegalie, put9nd fi atins tra8ea, ureterul, tractul
gastrointestinal
/ &ebra, scderea ponderal de #0<, trasnpiraiile nocturne sugerea0 un limfom agresi+
:imfoame
7iagnostic prin biopsie i e2 8istopatologic, Ce2 de laborator, rtg toracic, (3, puncie sternal
pentru stadiali0areD
!tadiile precoce" simptome nasofaringiene Climfadenopatie cre+ical uni/sau bilateral,
obstrucie na0al, epista2is, otit medieD
;n stadile a+ansate" trismus, disfagie, scdere ponderal, fumatul i consumul de alcool 6risc
crecut
(ancerele capului i g9tului
A2amenul endoscopic al organelor COF:D, (3, F4N, biopsie ganglionar dac nu s/a pus n
e+iden le0iunea primar
>denopatie +ariabil, splenomegalie, adenopatie mediastinal, paloare, peteii, purpur,
sindrom 8emoragipar, slbiciune, fatigabilitate, astenie, dispnee, infecii, incidena crescut la
copii i +9rstnicii peste *5 de ani
:eucemia acut limfoblastic
)emoleucogram/pancitopenie, peste %0< blati n 4O
:imfadenopatie general0at cu afectare nodulilor 8ilari, eritem nodos, dispnee, artralgii,
implicarea diferitelor sisteme
!arcoido0, poate fi luat n seam 35(, cancerul pulmonar, silico0a, infecii fungice
7g" date clinice, biopsie, e2 8istologic , Ftg t8oracic/adenopatie 8ilar bilateral C90<D,
8ipercalcemie, leucopenie, G+eim test po0iti+, 8iperglobulinemie, ni+el crescut al >(A C'0/
I0<D, reacia la 117/negati+
:imfadenopatie nedureroas locali0at cer+ical, deasupra diafragmuluiCI0<D, febr,
transpiraii nocturne, scdere ponderal, prurit generali0at, splenomegalie, se2ul masculine i
antecedentele familiale mresc riscul
:imfomul )odg,in Climfoame non/)odg,in, 3bc, sarcoido0D
7g 8istopatologic, Ftg toracic Cmas mediastinal, adenopatie 8ilar, biopsie osteomedular
:imfadenopatie locali0at sau generali0at CI0<D, splenomegalie C50<D, ras8 cutanat,
fatigabilitate, transpiraii, scdere ponderal, +9rsta medie de *5 de ani
:eucemia limfocitar cronic
:eucocito0 peste 20000@mmc cu limfocito0 peste .5< limfocite mature mici,
imunofenotiparea e+idenia0 (7 #9 sau (7 5, e2 8istologic, rtg toracic" adenopatie 8ilar,
mediastinal, 8ipogamaglobulinemie C50<D, 4O infiltrat cu limfocite mici
Noduli fermi, adereni n regiunea tiroidei, adenopatie cer+ical anterioar, +9rsta sub 20 sau
peste .0 de ani, brbai de 2 ori mai des,
(ancerul tiroidian
5iospia/aspiraia cu ac fin, ecografie, (3, F4N, 1A3, Ci pentru e+idenierea metasta0elorD,
testele tiroidiene standard de obicei normale
;n .0< a ca0urilor formaiune tumoral n s9n de obicei nedureroas, mai rar adenopatie
a2ilar ipsilateral, #I0000 de ca0uri annual n !J>
(ancerul mamar Cimplantul mamarD
4amografie pentru detectarea precoce, aspiraia cu ac fin, biopsie
>denopatie cer+ical, supracla+icular ipsilateral, adenopatie generali0at Cmeta
e2tratoraciceDdurer toracic, dispnee, 8emopti0ie, scdere ponderal, durere 8epatic, cae2ie,
risc crescut la fumtori
(ancerul pulmonar CCsilico0a, 3bcD
Ftg toracic/anormal, e2 8istologic din sput Ce2 citologicD, bron8oscopie sau biopsie (3
g8idat, biopsie din ggl limfatic sau din meta 8epatice
&aringit, stare alterat, febr, adenopatie cer+ical cu noduli mobili moi,poate fi generali0at,
splenomegalie la 50<, mai des la persoanele sub 25 de ani, )?$ po0iti+e
!indromul mononucleo0ei infecioase CA5$D, )?$, (4$, to2oplasmo0, infecii
streptococice, 8epatite 5, limfoame
)emoleucogram cu leucocito0 limfocitar, cu limfocite largi, atipice, testul monospot, test
pt A5$ CanticorpiD


7iagnosticul diferenial al limfadenopatiilor la bolna+i cu risc sc0ut ale 5!3 i cu le0iuni
tegumentare +i0ibile

!imptome i semne
(au0a posibil
3este recomandate
$e0icule, papule, pustule aprute la #/2 spm9ni dup 0g9rietur sau muctur de pisic,
c9ine, maimu, etc, limfadenopatie locali0at cu ggl moi, febr sau subfebrilitate, stare gen
alterat, ceaflee, inapeten
5oala g8earelor de pisic
3est serologic pentru ac anti 5artonella 8enselae, 8emoleucograma arat leucocito0 cu
neutrofilie, culture din aspiratul ganglionar, $!) mare
Aritema migrans Cerupie eritematoas circular care se e2tinde progresi+Dla #/2 sptm9ni
dup neptura de cpu, lifadenopatie locali0at la *0/I0< a ca0urilor, artralgii, i stare
general alterat n fa0ele precoce
5oala :Bme
A:?!> pt depistarea ?g4 sau ?gG pentru 5orrelia burgdorferi, Cconfirmat prin test Kestern
blotD
:imfadenopatie generali0at Cauriculari posterior, cer+icali, suboccipitali n specialDras8
maculo/papular care se e2tinde progresi+
Fubeola Cto2oplasmo0aD
A:?!> pt ?g4 sau ?gG, din biopsie ggl , s9nge, :(F, 1(F pentru >FN +iral
$e0icule i eritem distribuite pe teritoriul unei dermatoame, neuralgie, pareste0ii, febr,
cefalee, adenopatie locali0at, stare alterat, risc crecut la imunocompromii, n populaia
general risc de #0/20<, certe cu +9rsta
)erpes 0oster
A2amen clinic, e2 po0iti+ din lic8idul +e0icular
5oal febril acut, grupuri de noduli foarte moi, oc septic, Cfoate rar, #5 ca0uri pe an n
!J>D
(iuma Cinfecii sterptococcice, tularemia, boala g8erelor de pisicD
(ultur po0iti+ Caspirat din le0iuni, s9ngeDserologie pt Lersinia pestis, leucocito0 cu
trombocitopenie, rtg toracic, e2 :(F indicate
1apule moi, eritematoase, pruriginoase care se e2tend rapid, apropiat 0onei n care a fost
nepat de cpu sau mucat de animale, limfadonopatie locali0at Cn *5< a ca0urilorD, pot fi
necrotice sau supurate
3ularemia CM/infecii sterptococice, boala :Bme,
3est serologic de aglutinare n 2 sptm9ni, identificarea microscopic sau din culture a
&rancisella tularensis
:imfadenopatie moale, locali0at sau generali0at, febr mare, ondulant, stare alterat,
artralgii, urticarie sau ras8 popular pruriginos, edem facial Cmedicaie cu antibiotice,
anticon+ulsi+anteD
5oala comple2elor imune CNserum sic,nessOD sau 8ipersensibilitate la medicamente, C:A!,
8epatite, grip, (4$, )?$, A5$, limfoame, sifilis
/ (riterii clinice, (%, (', (50 sc0ut, $!) mare
/ teste funcionale 8epatice,


7iagnosticul diferenial al adenopatiilor la bolna+ii cu risc sc0ut de 5!3 i fr le0iuni
tegumentare

7ureri faringiene, febr, ggl cer+icali anteriori Cadenopatie cer+ical posterioar sau
generali0at sugerea0 A5$D
&aringite, streptococi din grupa > CA5$, gonoreaD
A2udat faringian Cculturi pt !treptococ beta 8emolitic grupa >, !treptococcus pBogenes,
Nodul unic sau n grupuri cer+icali sau generali0at, duri, febr C20/'0<D, stare alterat,
mialgii, 8epatosplanomegalie, e2posiie la pisic, m9ncruri insuficient preparate
contaminate, risc mare la imuno /compromii
3o2oplasmo0a
?0olarea 3o2oplasma gondi din s9nge, fluide biologice, teste serologice pt ac ?g4, ?gG,
biopsia ganglionar e+idenia0 8iperpla0ie folicular pot fi c8iste de to2oplasma
!imptome nespecificeP cefalee, febr, scdere ponderal, fatigabilitate, mialgii,
limfadenopatie generali0at sau locali0at, date epidemiologice sugesti+e Canimale domestice,
lapte nepasteuri0at, cltoriiD
5rucelo0a
3este serologie C1(FD, culturi din s9nge sau 4O Ccrete lent, de multe ori negati+eD, rtg de
sc8elet CspondiliteD
Jn procent de 25< a 35( e2trapulmonar se manifest ca limfadenit, ggl duri cer+ical
C.0<D, ing8inal, a2ilar
>denita tuberculoas Csracoido0, limfoame, cancereD
Feacia la 117 M la I0< a ca0urilor, biopsie ganglionar, 1(F, culturi pt b Goc8,




7iagnosticul diferenial al limfadenopatiilor la bolna+ii cu risc crescut de 5!3 sau boli
congenitale

!imptome
(au0a posibil
3este recomandate
>denopatie ing8inal bilateral, ferm la # sptm9n de apariia ulcerului de obicei
nedureros, fr simptome generale
!ifilisul primar
A2 microscopic prin imunofluorescen pentru 3reponema pallidum, $7F:, F1F po0iti+e
>denopatie generali0at ferm Cggl epitroc8leariD, ras8 maculopapular, le0iuni mucoase,
condiloame, semen generale
!ifilis secundar
:a fel
Jlcere genitale neindurate, dureroase, noduli ing8inali moi Cunilateral la *5<D, pot fi
suppurai, simptome generale pot fi
Qancrul Cpoate fi luat n considerare 8erpes genitalD
7e e2cludere a sifilisului i )!$, culture pentru )emop8Blus ducreBi
Jlcere sau +e0icule genitale dureroase, limfadenopatie ing8inal bilateral moale, poate fi
generali0at, mialgii, stare gen alterat, febr
)erpesul genital
3est rapid pt anticorpi, culture sau e2 >7N +iral )!$2, testele serologice Cneu0ulaeD
Noduli ing8inali moi, n grupuri, supurai Cunilateral n *.< a ca0urilorD, le0iunile primare de
obicei nedetectabile, proctit, stricture rectale, simptome generale,
:Bmp8ogranuloma +enereum
7ate clinice i teste positi+e pentru (8lamBdia trac8omatis Cfi2area complementului, A:?!>,
1(FD
Noduli moi, mai ales cer+ical i epitroc8lear, 8epatomegalie, greuir, +rsturi, ras8
maculopapular
)epatita 5
1robe funcionale 8epatice, >tg )5s, C?g4 anti )5c pt infecia acutD
>denopatie de obicei generali0at, febr stare alterat, ras8,
)?$
A:?!> C#00< po0iti+D, confirmat prin Kestern blot

7iagnosticul diferenial al adenopatiilor la bolna+ii cu antecedente familiale de boli
autoimmune


!imptome
5oala
3este recomandate
:imfadenopatie locali0at sau generali0at n '0< a ca0urilor, artralgii, ras8 malar, sero0ite,
afeciuni renale, neurologice, 8ematologice, gastrointestinale, la femei tinere de ./9 ori mai
des
:A!
(riterii >F> C' sau mai multeD, >N> 95/#00< sensiti+e, dar nespecific,
:imfadenopatie locali0at sau generali0at, poliartrite simetrice, dureri articulare, articulaii
amorite, pre+alena #<, femei de % ori m ai frec+ent
>F
(riteriile >F>, &F M la I0<





5ibliografie
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2
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&oerster E, :u,ens E, et al 18iladelp8ia" Killiams and Kil,insP #999"#I2#/%5
%
RR !imon )5 " 1rimarB (are 4edicine" Office A+aluation and 4anagement of t8e >dult
1atient, edn % Adited bB Goroll >), 4aB :>, 4ulleB E5 Er 18iladelp8ia" :ippincottP
#995"5'/I
'
)enrB 1), :ongo 7: " )arrisonSs 1rinciples of ?nternal 4edicine, edn #' Adited bB &auci
>!, 5raun-ald A, ?sselbac8er GE, et al Ne- Lor," 4cGra-/)illP #99I"%'5/.
5
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