LYMPHADENITIS

dr. Andi Irhamnia Sakinah

PSPD FKIK UINAM 2017

SKDI
4A
 LEARNING OUTCOME

 Mahasiswa mampu memahami definisi dan epidemiologi

limfadenitis
 Mahasiswa mampu memahami etiopatogenesis limfadenitis
 Mahasiswa mampu memahami manifestasi klinis limfadenitis
 Mahasiswa mampu memahami penegakan diagnosis
limfadenitis
 Mahasiswa mampu memahami diagnosis banding limfadenitis
 Mahasiswa mampu memahami penatalaksanaan limfadenitis
 Mahasiswa mampu memahami prognosis dan komplikasi
limfadenitis
BACKGROUNDS

 Lymphadenitis – Inflammation one or more lymph

nodes (infection)
 Causes: Bacteria, virus, protozoa, rickketsia or fungi.
 Infection spreads to the lymph nodes from focal
infection.
 Streptococcus, Staphylococcus, and Tuberculosis 
Most common cause
 Single node or a group of nodes (regional
adenopathy)
 Unilateral or Bilateral
 Early symptoms: Lymph node enlargement (Buildup of
fluid and increasing number of WBC due to immune
response against infection)
 Because infectious processes involving the
oropharyngeal structures are common in children,
cervical lymphadenitis is also common in this age
group.
 EPIDEMIOLOGY

 Study in Netherland, 2556 cases of lymphadenitis

 Referred to subspecialist 10%
 For biopsy 3.2%
 Malignancy 1.1%
 Children: most commonly from URTIs caused by Virus
 Tuberculous lymphadenitis
 Developing world: 43% of peripheral lymphadenopathy
 Rural India: Prevalence in children up to 14yo with 4.4 cases per 1000
 USA: Patients with TB, 30-40% have lymphadenitis
 ETIOLOGY
Infectious agents children aged 1-5 years  Group A streptococcal
(GAS) pharyngitis -
 Coccidioides immitis  Mycobacterium Submandibular and
(coccidioidomycosis) – tuberculosis - Mediastinal, anterior cervical;
Mediastinal mesenteric, anterior unilateral, firm, tender
cervical, localized disease
 Cytomegalovirus – (discrete, firm, mobile,  Toxoplasma gondii -
Generalized tender); generalized Generalized, often
hematogenous spread nontender
 Dental caries/abscess – (soft, fluctuant, matted,
Submaxillary and adhere to overlying,  Viral pharyngitis - Bilateral
erythematous skin) postcervical; firm, tender
 Epstein-Barr virus
(mononucleosis) - Anterior  Parvovirus - Posterior  Yersinia enterocolitica -
cervical, mediastinal, auricular, posterior Cervical or abdominal
bilateral; discrete, firm, cervical, occipital
nontender  Yersinia pestis (plague) -
 Rubella - Posterior Axillary, inguinal, femoral,
 Francisella tularensis auricular, posterior cervical; extremely tender
(tularemia) - Cervical, cervical, occipital with overlying erythema
mediastinal, or
generalized; tender  Salmonella – Generalized
 Histoplasma capsulatum  Seborrheic dermatitis,
(histoplasmosis) – scalp infections - Occipital,
Mediastinal postauricular
 Atypical Mycobacterium -  Staphylococcus aureus
Cervical, submandibular, adenitis - Cervical,
submental (usually submandibular; unilateral,
unilateral); most commonly firm, tender
in immunocompetent
 ETIOLOGY

 Immunologic or connective tissue disorders (Graft vs Host

Disease)
 Primary diseases of lymphoid or reticuloendothelial tissue (eg ALL,
NHL)
 Immunodeficiency syndromes and phagocytic dysfunction (eg
AIDS)
 Metabolic and storage diseases (eg Gaucher disease)
 Hematopoietic diseases (ie sickle cell anemia, thalassemia)
 Miscellaneous disorders (ie Kawasaki disease, sarcoidosis)
 Medications
 CLASSIFICATION

 Acute : 2 weeks
 Viral/bacterial infection
 Surgeons aren’t involved unless lymph nodes become suppurative
 Subacute : 2-6 weeks

 Chronic : >6 weeks

 Neoplastic process/infiltration opportunistic organism
 PATHOGENESIS

 Multiplication of cells within the node, including lymphocytes,

plasma cells, monocytes, or histiocytes
 Cellular hyperplasia
 Infiltration of cells from outside the node, such as malignant cells
or neutrophils
 Draining of an infection (eg, abscess) into local lymph nodes
 Tenderness results from distention of the nodal capsule
 DIAGNOSIS

 History Taking
 Physical Exam
 Complaints

 Age
 Onset
 URTIs symptoms, sore throat, earache, coryza, conjunctivitis,
impetigo
 Lymph node enlargement
 Fever
 Loss of appetite
 Fatigue
 Arthralgia
 Risk Factors

 History of tonsilitis, teeth and gum infection

 Contact with animals, especially kittens or livestock
 Recent dental care or poor dental health
 Recent use of hydantoin and/or mesantoin
 Travel and employment history in endemic area
 Exposure from infection like person with URTI, pharyngitis, or
tuberculosis  Lymphadenopathy
 Physical Exam

 Retropharyngeal node inflammation  dysphagia or dyspnea.

 Mediastinal lymphadenitis  cough, dyspnea, stridor, dysphagia,
pleural effusion, or venous congestion.
 Intra-abdominal (mesenteric and retroperitoneal) adenopathy
 abdominal pain.
 Iliac lymph node involvement  abdominal pain and limping.
 Enlarged lymph nodes  asymptomatic, or local pain and
tenderness. Overlying skin may be unaffected or erythematous.
 Location - Depends on underlying etiology
 Number - Single, local groupings (regional), or generalized (ie,
multiple regions)
 Size/shape
 Consistency - Soft, firm, rubbery, hard, fluctuant, warm
 Tenderness - Suggestive of an infectious process but does not rule out
malignant causes
 Work-Up

 CBC
 Identify the etiology
 Gram stain
 Culture of tissue or biopsy
 Serologic tests
 Liver function tests
 Tuberculosis screening
 PPD
 Blood Sedimentation Rate
 Acid Fast Bacilli (sputum)
 Mantoux test
 Imaging: US, CXR
 Procedures: FNA, biopsy
 DIFFERENTIAL DIAGNOSIS

 Mumps
 Thyroglossal Duct Cyst
 Dermoid Cyst
 Hemangioma
 TREATMENT

 Sanitation and hygiene → Infection

 Warm pack
 Symptomatic
 Depends on etiology
 Viral infection  Self limiting disease (observation)
 Bacterial infection
 Oral antibiotic for 10 days, FU first 2day
 Flucloxacillin 25 mg/kg divided q6hr
 Cephalexin 25 mg/kg (max. 500 mg) OR Erythromycin 15 mg/kg (max. 500 mg)
divided 8hr.

 Mycobacterium tuberculosis  ATDs (OAT)

 COMPLICATION

 Abscess formation
 Cellulitis (Skin infection)
 Sepsis (systemic involvement)
 Fistule (appear on Lymphadenitis ec. TB)
 Etc.
 PROGNOSIS

 Mostly bonam
 Prognosis depends on the etiology of the lymphadenopathy and
timing of intervention.
 WHEN DO WE REFER THE
PATIENTS?
 Failure to shrink after 4-6weeks  Biopsy
 Persistent after adequate therapy
 Couldn’t make the diagnosis
 COUNSELING & EDUCATION

 Family hygiene to prevent infection and transmission

 Support and motivate the patient to complete the treatment
WASSALAM,
THANKYOU 
 You proceed to perform a careful physical examination of the boy. You palpate
each region of the body for lymphnodes. An enlarged lymph node in which of the
following locations would be most concerning for malignancy?
 A. Anterior cervical. B. Inguinal.
C. Posterior cervical. D. Submandibular. E. Supraclavicular.

 A 4-year-old girl presents with a 10-day history of unilateral anterior cervical lymph
node enlargement. She has
a temperature of 39.5oC. The node is approximately 2 cm in diameter, warm, and
fluctuant. The only pertinent finding on physical examination is mild pharyngeal
erythema. You suspect acute bacterial lymphadenitis. Of the following, which are
the most likely infectious agents to cause lymphadenitis in a 5-year-old?
 A. Bartonella and Staphylococcus.
B. Epstein-Barr virus and Staphylococcus.
C. Mycobacterium tuberculosis and Staphylococcus. D. Staphylococcus and
Streptococcus.
E. Toxoplasma and Nocardia.
 ANSWER AND EXPLAIN!

 An8-year-
oldboypresentstoyourclinicwithprogressiveenlargementofarightaxillarynode,
nowtender,anddaily fevers (up to 38.6oC). You discover that the boy has
been playing frequently with his family’s new kitten. You suspect the child
may have a specific bacterial infection and he is uncomfortable enough to
treat. Of the following, which is the preferred antibiotic?
A. Amoxicillin. B. Azithromycin. C. Cephalexin. D. Doxycycline. E. Penicillin.
 A 16-year-old girl presents with 2 weeks of fatigue, fever, and sore throat. On
examination, you identify enlarged posterior and anterior cervical nodes,
and a palpable spleen tip. She has mild thrombocytopenia (platelet count
of 120 3 103/mL [120 3 109/L]). Of the following, which would be the most
specific test to confirm the suspected diagnosis?
A. Bartonella henselae antibody titers.
B. Epstein-Barr virus antibody titers.
C. HIV antibody titers.
D. Throat culture for group A Streptococcus.
E. White blood cell count with differential.