Infectious disease causes of lymphadenopathy: localized versus diffuse

Lymphadenopathy is commonly associated with numerous infectious diseases. The evaluation of lymphadenopathy may reveal local (regional) node involvement or diffuse (generalized) node involvement. Additional assessment factors used to evaluate the lymphadenopathy include the anatomic location, node characteristics, associated symptoms, medical and social history, and comprehensive physical examination fundings. Infectious diseases that cause generalized lymphadenopathy include HIV disease, toxoplasmosis, secondary syphilis, and tuberculosis. This article discusses the evaluation of lymphadenopathy, infectious causes of generalized lymphadenopathy, as well as those infections that cause regional lymphadenopathy.     

Cervical Lymphadenopathy—Pitfalls of Blind Antitubercular Treatment

Tuberculosis (TB) is the most common cause of cervical lymphadenopathy in the TB-endemic zone, like India but it can also mimic other diseases. Four cases of cervical lymphadenopathy presented to us as initial treatment failure after completion of six months of antitubercular drugs (ATD), including rifampicin, isoniazid, pyrazinamide, and ethambutol. All were diagnosed as having tuberculosis either by fine needle aspiration cytology or clinically from outside our institution. In one case, tuberculosis was the final diagnosis but, unfortunately, it was multidrug-resistant. In other three cases, Hodgkin disease, Non-Hodgkin lymphoma, and Kikuchi''s disease were the diagnoses. In resource-poor countries, like India, which is also a TB-endemic zone, TB should be the first diagnosis in all cases of chronic cervical lymphadenopathy, based on clinical and/or cytological evidences. So, they were correctly advised antitubercular therapy (ATT) initially. Sometimes, TB mimics other aetiologies where apparent initial improvement with ATT finally results in treatment failure. Hence, investigations for microbiological and histopathological diagnosis are warranted, depending on the resources and feasibility. If these tests are not routinely available, the patients should be under close monitoring so that lymphoma, drug-resistant TB, or other aetiologies of cervical lymphadenopathy are not missed. Patients with cervical lymphadenopathy rarely presents acutely; so, a physician can take the opportunity of histopathological study of lymphnode tissue.Key words: Cervical lymphadenopathy, Excision biopsy, Hodgkin disease, Kikuchi''s disease, Non-Hodgkin lymphoma, Tuberculosis     

Unexplained lymphadenopathy in family practice. An evaluation of the probability of malignant causes and the effectiveness of physicians' workup

This study reported here was undertaken to determine the probability of malignancy in patients presenting with unexplained lymphadenopathy in primary care practice and to estimate the effectiveness of current referral patterns by family physicians in relation to malignant disease. Clinical characteristics that may be discriminatory for malignant causes were also investigated. A retrospective analysis was performed of 82 patients who underwent biopsy for unexplained lymphadenopathy from 1982 to 1984; data regarding the incidence of unexplained lymphadenopathy and the referral rate for this problem were obtained from registration projects. A total of 29 malignant lymphadenopathies were identified for a prior probability of 1.1 percent and a posterior (after referral) probability of 11 percent. The ability of the family physician to refer malignant cases within four weeks after initial consultation (sensitivity of referral) was 80 to 90 percent; 91 to 98 percent of benign cases were not referred (specificity of referral). An increased likelihood of malignancy was associated with age over 40 years (4 percent) and supraclavicular lymphadenopathy (50 percent). The incidence of malignancy in patients presenting with unexplained lymphadenopathy to the family physicians is very low (1 to 2 percent). Nevertheless, despite the paucity of validated discriminatory factors, the family physicians perform a reasonably effective selection process toward referral and biopsy.     

A case of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) together with total atelectasis of a lung caused by lymphadenopathy and pleural effusion

Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) is a clinicopathologic entity established by Frizzera in 1974. Reported cases of AILD with pleuropulmonary involvement have been increasing recently. At Nogata Central Hospital, an 82-year-old male inpatient with brain infarctions and chronic bronchitis showed a rapid growth of systemic lymphadenopathy and various other symptoms. We diagnosed the case as AILD by histopathologic examination of a lymph node. Chest radiography and computed tomography demonstrated a loss of volume of the right lung caused by intrathoracic lymphadenopathy and a pleural effusion. Although cases of AILD with pleuropulmonary involvement have been increasing, no cases with almost total atelectasis of a lung have been reported as yet. AILD should be taken into account as a disease which may cause atelectasis of a lung.     

彩色多普勒超声对颈部淋巴结诊断价值的分析

目的探讨彩色多普勒超声(CDFI)对颈部淋巴结的诊断价值,提高彩超对不同疾病所致淋巴结肿大的鉴别诊断水平。方法应用彩超观察共62例124个颈部肿大淋巴结(分良、恶性两组)的长径与短径之比(L/S),内部回声及CDFI血流特征。结果良性肿大淋巴结形态呈椭圆形,L/S比值>2,内部回声多为髓质增强、增宽,皮质相对变窄,门部回声规则存在。恶性肿大淋巴结形态呈类圆形,L/S比值<2,内部回声以皮质低回声为主,或强弱不等或非均匀性增厚,髓质及门部强回声变形偏移、不规则或消失。CDFI示良性肿大淋巴结内多呈门部规则血流,呈低速低阻型,部分未见血流。恶性肿大淋巴结内多呈不规则血流及周边包绕血流,血流速度Vmax及阻力指数RI显著高于良性组(P<0.01)。结论根据彩色多普勒血流及二维声像图特点、结合病史等,超声检查对颈部肿大淋巴结良、恶性鉴别有一定诊断价值,可作为首选方法。     

儿童亚急性坏死性淋巴结炎8例分析

目的：探讨儿童亚急性坏死性淋巴结炎（SNL）临床特征及诊治结果。方法：对8例SNL患儿进行回顾分析。结果：8例儿童SNL临床表现均有淋巴结肿大，发热和白细胞减少为主要临床表现，8例中曾有4例误诊，误诊率50.0％，需与淋巴结结核、恶性淋巴瘤、传染性单核细胞增多症等鉴别。结论：激素活疗有效，预后良好。     

Cervical lymphadenopathy in children

The management of cervical lymphadenopathy in children varies widely between clinicians. It is recognized that clinical management can be improved by standardizing the diagnostic and treatment methods. This article presents an algorithm based on the available evidence for the management of cervical lymphadenopathy in children.     

Mycobacterium haemophilum as the cause of lymphadenitis in the neck in an otherwise healthy boy

In an 8.5-year-old boy with severe recurring unilateral swelling of the neck, infection with Mycobacterium haemophilum was established. In addition to the more usual causative agents, cervical lymphadenopathy in children can, in rare cases, be caused by M. haemophilum. The skin tests did not differentiate between Mycobacterium avium and Mycobacterium tuberculosis infection. There was no evidence of specific immune deficiencies. The swelling did not respond to treatment with four tuberculostatic drugs (rifampicin, isoniazid, pyrazinamide and ethambutole), nor to repeated surgical excision. Finally, M. haemophilum grew on the culture despite sub-optimal culture conditions. Thereupon the patient was treated with co-trimoxazole and recovered in two weeks. This is the first patient with cervical lymphadenopathy caused by M. haemophilum to be described in the Netherlands. M. haemophilum grows on an iron-rich medium at a relatively low temperature (30-32 degrees C). In cases of cervical lymphadenopathy, it is advisable to consider M. haemophilum as a cause and to adjust the culture conditions accordingly.     

Rickettsia slovaca and R. raoultii in Tick-borne Rickettsioses

Tick-borne lymphadenopathy (TIBOLA), also called Dermacentor-borne necrosis erythema and lymphadenopathy (DEBONEL), is defined as the association of a tick bite, an inoculation eschar on the scalp, and cervical adenopathies. We identified the etiologic agent for 65% of 86 patients with TIBOLA/DEBONEL as either Rickettsia slovaca (49/86, 57%) or R. raoultii (7/86, 8%).     

Thrombocytopaenia as the presenting feature of persistent generalised lymphadenopathy (PGL) in a one-year-old

A one-year-old child who presented with thrombocytopaenia was found to be HIV positive and has now developed persistent generalised lymphadenopathy (PGL).     

Tuberculous paraspinal abscess: a case of mistaken identity

We present the case of a 35-year-old man of Pakistani origin presenting with a history suggestive of tuberculosis. Chest x-ray revealed left upper zone consolidation and mediastinal widening felt to be consistent with mediastinal lymphadenopathy. Bronchoalveolar lavage failed to yield acid-fast bacilli (AFB) and therefore CT thorax was requested with a view to surgical referral for mediastinal node biopsy. CT thorax revealed a large paravertebral abscess to be the cause of apparent mediastinal widening. CT guided biopsy confirmed Mycobacterium tuberculosis on culture. On reflection, there was preservation of the right paratracheal stripe on chest x-ray indicating that this was not mediastinal lymphadenopathy but a paravertebral mass as illustrated on CT.     

Atypical American visceral leishmaniasis caused by disseminated Leishmania amazonensis infection presenting with hepatitis and adenopathy

Leishmania amazonensis is widely recognised as a cause of cutaneous leishmaniasis in Latin America, but it can also disseminate to produce atypical visceral leishmaniasis with hepatitis and lymphadenopathy. The patient, an 8-year-old Brazilian boy, presented with a febrile illness and hepatosplenomegaly, elevated liver enzymes and generalised adenopathy. Serological tests using antigens of L. chagasi, the typical cause of visceral leishmaniasis in Latin America, were inconclusive. Leishmania amazonensis was eventually isolated in a culture of a lymph node. The patient recovered fully after treatment with meglumine antimoniate. As this case illustrates, L. amazonensis produces a spectrum of disease that includes atypical American visceral leishmaniasis with evidence of hepatocellular injury and generalised lymphadenopathy.     

Misinterpreted lymphadenopathy and thrombocytopenia as unrecognised initial symptoms of an HIV-infection

In a 28-year-old woman and a 30-year-old man with lymphadenopathy, shown by histopathology to be follicular hyperplasia, and in a 40-year-old woman and a 40-year-old man with a thrombocytopenia, HIV-infection was not diagnosed until years later. Three of the four patients did not belong to a 'classical high-risk group' for HIV/AIDS. All patients, meanwhile, suffered from minor or major complications. Moreover, the number of CD4+ cells had decreased to < or = 200/microl before antiretroviral therapy was started. After treatment, all four patients were in reasonable to good condition. An HIV-infection should be considered in every case of reactive lymphadenopathy or thrombocytopenia.     

Localisation hépatique de la maladie des griffes du chat chez un immunocompétent

Introduction

The cat-scratch disease is a benign inoculation disease and a well-known cause of localized lymphadenopathy. Visceral localizations are rare and occur mostly in immunocompetent patients.

Case

We report the case of a 57-year-old-man with lymphadenopathy of the right arm with hepatic nodules related to a Bartonella henselae infection.

Conclusion

The cat-scratch disease must be screened for in case of hepatic and/or splenic nodules. A cause of immunodeficiency should be investigated.     

Screening tests for diagnosis of cervical lymphadenopathy presenting as prolonged fever

During a two years period, 16 cases having cervical lymphadenopathy presenting as prolonged fever were studied in Abbassia fever hospital, Cairo, Egypt. Patients were subjected to careful history, thorough clinical examination, complete blood picture, tuberculin test, chest x-ray, Monospot test, indirect fluorescent antibody test for toxoplasmosis, detection of cytomegalovirus antibodies and lymph node biopsy with histopathological examination. Ten within normal subjects were taken as controls. The patients were grouped on histopathological basis into 5 groups: (1) One (6%) of the cases was non-specific lymphadenitis diagnosed by clinical examination of the scalp and leucocytosis with polymorphonuclear predominance. (2) Reactive lymphadenitis included 6 (38%) of the cases. Infectious mononucleosis cases were diagnosed by clinical triad of fever, pharyngitis and cervical lymphadenopathy, relative lymphocytosis, monocytosis and positive monospot test. Cytomegalovirus case was diagnosed by lymphocytosis, monocytosis and negative monospot test. Toxoplasmosis cases were diagnosed by monocytosis, negative tuberculin test and positive indirect fluorescent antibody test. (3) Granulomatous lymphadenitis comprised 6 (3%) of the cases. Tuberculous cases were diagnosed by high ESR and highly positive tuberculin test. Sarcoidosis cases were diagnosed by negative tuberculin test and presence of hilar lymphadenopathy. (4) Non-Hodgkin lymphoma case (6%) was diagnosed by clinical deterioration and total lymph node biopsy. 15) Systemic infections were diagnosed by clinical examination, blood culture for salmonellae and brucellae, Widal and Brucella agglutination tests. It is concluded from this study that screening tests are important aids in the diagnosis of cases of cervical lymphadenopathy presenting by prolonged fever especially if lymph node biopsy and histopathological examination are not available or contraindicated. Tub     

Lymphadenopathy in a family practice: a descriptive study of 249 cases

The charts of 249 patients with enlarged lymph nodes were audited to provide a further primary care data base and to clarify recommendations for evaluation of lymphadenopathy. A firm diagnosis was made in only 36 percent of patients despite an average of 1.7 visits and two laboratory tests per patient tested. Serious or treatable causes of lymphadenopathy were rare and were always accompanied by clinical conditions that suggested further evaluation. Lymph nodes were biopsied in only 3 percent of patients. No patient was found to have a prolonged, disabling illness without a prompt diagnosis. The data suggest that, in patients without associated signs or symptoms, a period of observation is safe and likely to save unnecessary expense and biopsy.     

Diagnostic imaging (257). A boy with a swollen inguinal gland

In a 4-year-old boy with left-sided inguinal lymphadenopathy and a papule on his left lower leg situated at the end of a scar of a probable cat scratch, cat scratch disease was confirmed serologically.     

Analysis of mediastinal lymphadenopathy in sarcoidosis with transesophageal ultrasonic endoscopy; influences on cardiovascular system

We studied influences of mediastinal lymphadenopathy on cardiovascular system in nine cases of sarcoidosis with transesophageal ultrasonic endoscopy. Chest x-ray films revealed bilateral hilar lymphadenopathy in all cases, whose diagnoses were made histologically with biopsies of peripheral lung through flexible fiber optic bronchoscope and/or of lymph nodes. These findings were typical in this disease. Many compartments of cardiovascular system in mediastinal and hilar regions were visible with this technique in all subjects. And enlarged lymph nodes changed dimensions in these compartments, especially in main pulmonary arteries, left atria, pulmonary veins and aorta. Furthermore, these phenomena were seen in azygos vein and superior caval vein in some cases. It is suggested that these lymph nodes may influence hemodynamics in above-mentioned compartments of cardiovascular system, if this phenomenon deteriorates more progressively.     

Diagnosis and treatment of HIV-related Kaposi's sarcoma

A 42-year-old heterosexual man presented with bluish-purple spots on his skin and in his mouth cavity that had been present for a few months; a 48-year-old homosexual man had painful lymphadenopathy in the groins and left axilla. Both men appeared to have a Kaposi's sarcoma and to be HIV-positive. During highly active antiretroviral therapy (HAART) and radiotherapy or chemotherapy, both the AIDS parameters and the skin lesions improved. Kaposi's sarcoma is AIDS-defining in HIV-seropositive patients. Human herpesvirus-8 infection seems to play a role in the development of Kaposi's sarcoma. The incidence of Kaposi's sarcoma has declined since the introduction of HAART. Nowadays, Kaposi's sarcoma is frequently the presenting symptom of HIV-seropositivity. Patients present with purple cutaneous lesions and/or generalised lymphadenopathy. Visceral lesions are associated with a shorter median survival. The treatment of Kaposi's sarcoma is palliative, whereas immune restitution can lead to regression of the sarcoma.     

Drug rash with eosinophilia and systemic symptoms (DRESS) attributed to the oral skin-care supplement Imedeen

In a 56-year-old woman, 'drug rash with eosinophilia and systemic symptoms' (DRESS) was diagnosed. She had been admitted to hospital twice in two months because of fever and skin rash. Further studies revealed that in addition to the skin rash, the woman also suffered from eosinophilia, lymphadenopathy and a temporary liver-function disorder. After infectious and malignant causes had been excluded, the DRESS syndrome was diagnosed. The syndrome was attributed to the oral skin-care supplement Imedeen. She had stopped using this preparation previously, after which the symptoms decreased markedly. Now she was treated with corticosteroids and methotrexate and recovered completely after almost four months. The DRESS syndrome is characterised by skin rash, fever, lymphadenopathy and haematological abnormalities, especially eosinophilia and/or atypical lymphocytosis. Single or multiple organ involvement, especially of the liver, kidney, lungs and/or heart, is also common. The syndrome is associated with a number of different drugs.