Lymphadenopathy and Diseases of the Spleen




Abstract


Lymphadenopathy and splenomegaly are common findings in children. Both benign and malignant processes can produce these findings and it is important to distinguish between the two so that appropriate management can be undertaken.




Keywords

Lymphadenopathy, splenomegaly, lymph node biopsy, splenic visceroptosis, splenectomy, overwhelming postsplenectomy infection (OPSI)

 


Lymphadenopathy and splenomegaly are common findings in children. Both benign and malignant processes can produce these findings and it is important to distinguish between the two so that appropriate management can be undertaken.




Lymphadenopathy


Enlarged lymph nodes are commonly found in children. Lymphadenopathy might be caused by proliferation of cells intrinsic to the node, such as lymphocytes, plasma cells, monocytes, or histiocytes, or by infiltration of cells extrinsic to the node, such as neutrophils and malignant cells. In most instances, lymphadenopathy represents transient, self-limited proliferative responses to local or generalized infections.


Reactive hyperplasia, defined as a polyclonal proliferation of one or more cell types, is the most frequent diagnosis found in lymph node biopsies in children.


Lymphadenopathy, however, may be a presenting sign of malignancies such as leukemia, lymphoma, or neuroblastoma. It is important to be able to differentiate benign from malignant lymphadenopathy clinically. Lymphadenopathy in the head and neck region must be differentiated from several other nonlymphatic masses due to congenital malformations ( Table 4.1 ).



Table 4.1

Differential Diagnosis of Nonlymph Node Masses in Neck








  • Cystic hygroma



  • Branchial cleft anomalies, branchial cysts



  • Thyroglossal duct cysts



  • Epidermoid cysts



  • Neonatal torticollis



  • Lateral process of lower cervical vertebra may be misdiagnosed as supraclavicular node



Systematic palpation of the lymph nodes is important and should include examination of the occipital, posterior auricular, preauricular, tonsillar, submandibular, submental, upper anterior cervical, lower anterior cervical, posterior upper and lower cervical, supraclavicular, infraclavicular, axillary, epitrochlear, and popliteal lymph nodes. Many children have small palpable nodes in the cervical, axillary, and inguinal regions which are usually benign in nature.


When a child presents with lymphadenopathy, management is based on the following factors.


History


This involves the duration of the lymphadenopathy; presence of fever; recent upper respiratory tract infection; sore throat; skin lesions or abrasions, or other infections in the lymphatic region drained by the enlarged lymph nodes; immunizations; medications; previous cat scratches, rodent bites, or tick bites; arthralgia; sexual history; transfusion history; travel history; and consumption of unpasteurized milk. Significant weight loss, night sweats, or other systemic symptoms should also be recorded as part of the patient’s history.


Age


Although in young children cervical lymphadenopathy, especially in the upper cervical region, is usually due to infection, more serious disorders may have to be considered.


In children younger than 6 years, the most common cancers of the head and neck are neuroblastoma, rhabdomyosarcoma, leukemia, and non-Hodgkin lymphoma. In children 7–13 years of age, non-Hodgkin lymphoma and Hodgkin lymphoma are equally common, followed by thyroid carcinoma and rhabdomyosarcoma; and for those older than 13 years Hodgkin lymphoma is the more common cancer encountered.


Location


Enlargement of tonsillar and inguinal lymph nodes is most likely secondary to localized infection; enlargement of supraclavicular and axillary lymph nodes is more likely to be of a serious nature. Enlargement of the left supraclavicular node, in particular, should suggest a malignant disease (e.g., lymphoma or rhabdomyosarcoma) arising in the abdomen and spreading via the thoracic duct to the left supraclavicular area. Enlargement of the right supraclavicular node indicates intrathoracic lesions because this node drains the superior areas of the lungs and mediastinum. Palpable supraclavicular nodes are an indication for a thorough search for intrathoracic or intraabdominal pathology.


Localized or Generalized


Lymphadenopathy is either localized (one region affected) or generalized (two or more noncontiguous lymph node regions involved). Although localized lymphadenopathy is generally due to local infection in the region drained by the particular lymph nodes, it may also be due to malignant disease, such as Hodgkin lymphoma or neuroblastoma. Generalized lymphadenopathy is caused by many disease processes. Lymphadenopathy may initially be localized and subsequently become generalized.


Size


Nodes in excess of 2.5 cm should be regarded as pathologic. In addition, nodes that increase in size over time are significant.


Character


Malignant nodes are generally firm and rubbery. They are usually not tender or erythematous. Occasionally, a rapidly growing malignant node may be tender. Nodes due to infection or inflammation are generally warm, tender, and fluctuant. If infection is considered to be the cause of the adenopathy, it is reasonable to give a 2-week trial of antibiotics. If there is no reduction in the size of the lymph node within this period, careful observation of the lymph node is necessary. If the size, location, and character of the node suggest malignant disease, the node should be biopsied.


Diagnosis of Lymphadenopathy


Table 4.2 outlines the differential diagnosis of lymphadenopathy.



Table 4.2

Differential Diagnosis of Lymphadenopathy







  • 1.

    Nonspecific reactive hyperplasia (polyclonal)


  • 2.

    Infection



    • a.

      Bacterial: Staphylococcus , Streptococcus , anaerobes, tuberculosis, atypical mycobacteria, Bartonella henselae (cat scratch disease, brucellosis, Salmonella typhi , diphtheria, Chlamydia trachomatis lymphogranuloma venereum), Calymmatobacterium granulomatis , Francisella tularensis


    • b.

      Viral: Epstein–Barr virus, cytomegalovirus, adenovirus, rhinovirus, coronavirus, respiratory syncytial virus, influenza, coxsackie virus, rubella, rubeola, varicella, HIV, herpes simplex virus, human herpes virus 6 (HHV-6)


    • c.

      Protozoal: Toxoplasmosis, malaria, trypanosomiasis


    • d.

      Spirochetal: Syphilis, Rickettsia typhi (murine typhus)


    • e.

      Fungal: Coccidioidomycosis (valley fever), histoplasmosis, Cryptococcus , aspergillosis


    • f.

      Postvaccination: Smallpox, live attenuated measles, DPT, Salk vaccine, typhoid fever



  • 3.

    Connective tissue disorders



    • a.

      Rheumatoid arthritis


    • b.

      Systemic lupus erythematosus



  • 4.

    Hypersensitivity states



    • a.

      Serum sickness


    • b.

      Drug reaction (e.g., Dilantin, mephenytoin, pyrimethamine, phenylbutazone, allopurinol, isoniazid, antileprosy, and antithyroid medications)



  • 5.

    Lymphoproliferative disorders ( Chapter 16 )



    • a.

      Angioimmunoblastic lymphadenopathy with dysproteinemia


    • b.

      X-linked lymphoproliferative syndrome


    • c.

      Lymphomatoid granulomatosis


    • d.

      Sinus histiocytosis with massive lymphadenopathy (Rosai–Dorfman disease)


    • e.

      Castleman disease benign (giant lymph node hyperplasia, angiofollicular lymph node hyperplasia)


    • f.

      Autoimmune lymphoproliferative syndrome (ALPS) (Canale–Smith syndrome)


    • g.

      Posttransplantation lymphoproliferative disorder (PTLD)



  • 6.

    Neoplastic diseases



    • a.

      Hodgkin and non-Hodgkin lymphomas


    • b.

      Leukemia


    • c.

      Metastatic disease from solid tumors: neuroblastoma, nasopharyngeal carcinoma, rhabdomyosarcoma, thyroid cancer


    • d.

      Histiocytosis



      • i.

        Langerhans cell histiocytosis


      • ii.

        Familial hemophagocytic lymphohistiocytosis


      • iii.

        Macrophage activation syndrome


      • iv.

        Malignant histiocytosis




  • 7.

    Storage diseases



    • a.

      Niemann–Pick disease


    • b.

      Gaucher disease


    • c.

      Cystinosis



  • 8.

    Immunodeficiency states



    • a.

      Chronic granulomatous disease


    • b.

      Leukocyte adhesion deficiency


    • c.

      Primary dysgammaglobulinemia with lymphadenopathy



  • 9.

    Miscellaneous causes



    • a.

      Kawasaki disease (mucocutaneous lymph node syndrome)


    • b.

      Kikuchi–Fujimoto disease (self-limiting histiocytic necrotizing lymphadenitis)


    • c.

      Sarcoidosis


    • d.

      Beryllium exposure


    • e.

      Hyperthyroidism


    • f.

      Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA syndrome)




Figure 4.1 provides a diagnostic algorithm for evaluation of mononucleosis-like illness and Figure 4.2 for diagnostic evaluation of cervical lymphadenitis.


Jul 3, 2019 | Posted by in HEMATOLOGY | Comments Off on Lymphadenopathy and Diseases of the Spleen

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