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Lymphadenitis

Lymph Node Infection

Lymphadenitis is an infection of one or more lymph nodes and a common feature in a variety of disorders.


Presentation

In some cases, lymphadenitis remains asymptomatic. When symptomatic, the lymph node may be swollen and palpable with pain and tenderness. Neck stiffness is a common symptoms with cervical lymph node enlargement and often seen in infectious mononucleosis and cat scratch fever. Preauricular lymphadenitis is common in infections like conjunctivitis, and keratoconjunctivitis. Inflammation of the retropharyngeal node causes dysphagia and dyspnea. Patients with node enlargement in mediastinum may present with cough, stridor, pleural effusion, and dysphagia. Abdominal pain is common in cases where the intraabdominal nodes are enlarged and in iliac node enlargement. Supraclavicular lymphadenopathy has the highest risk of malignancy. Malignancy often results in hard, nontender, and firm nodes. Lymph node enlargement caused by infections is soft, tender and movable. Erythema of the skin is noted in some of the swollen nodes associated with infectious diseases. In many cases, the manifestations of the underlying disease may appear only after the initial lymph gland inflammation or enlargement.

Increased risk of lymphadenitis is seen in patients who have a clinical history of upper respiratory tract infection, conjunctivitis, persistent fever, and anorexia. Those who have a history of contact with animals or livestock also are at a high-risk of developing this condition.

Wound Infection
  • Depending on the duration and intensity of the inflammatory process, there are: acute lymphadenitis, which is characterized by a sudden onset and occurs as a result of wound infection, the development of an acute infectious disease, or after surgery;[en.medicine-worlds.com]
  • Despite perioperative prophylaxis with flucloxacillin, Staphylococcus aureus wound infections were observed in 6 patients (12%) and occurred within 2 weeks after the operation.[academic.oup.com]
  • One study examined 360 children undergoing excisional biopsy and found that 24 percent of patients had complications, such as hypertrophic scarring, recurrence, hematoma formation, wound infection, and nerve palsy, that were related to the procedure.[aafp.org]
Inguinal Mass
  • We present the case of a 60-year-old man with 7-month history of a growing inguinal mass/tumour, which was misdiagnosed as inguinal chronic lymphadenitis.[ncbi.nlm.nih.gov]
  • Here, we present 2 unusual cases of localized necrotic herpes simplex lymphadenitis in nonimmunosuppressed patients both with painful inguinal masses without cutaneous herpes lesions or constitutional symptoms.[journals.lww.com]
Rigor
  • The aim of the presentation is to describe these common skin manifestations, however seen in a primary cutaneous B-cell lymphoma, which underlines the necessity of rigorous monitoring/long-term follow-up as well as exhaustive histopathological analysis[ncbi.nlm.nih.gov]
  • While on antiTB treatment for 2 months she was admitted to this hospital with history of symmetrical arthritis of bilateral hands and legs, persisting intermittent low grade fever without chills or rigors, and backache.[jmedicalcasereports.biomedcentral.com]
Soft Tissue Mass
  • Hepaticojejunostomy was performed and pathologic analysis of the conglomerated soft-tissue mass revealed chronic granulomatous inflammation with caseation of the lymph nodes.[ncbi.nlm.nih.gov]
Insect Bite
  • Avoiding skin injury, insect bites, and scratches on the skin will go a long way in preventing infections and thus lymphadenitis. One should take care to treat skin ulcers promptly and appropriately.[symptoma.com]
Neck Swelling
  • Some of the common symptoms of Cervical Lymphadenitis are: Swelling of the lymph nodes in neck Swelling of the lymph nodes under jaw Presence of lumps under skin Swelling in the neck Pain in the neck Facial swelling Fever and chills Persistent sore throat[epainassist.com]
  • , abscess was seen in 10% of cases and discharging sinus in 2.14% of cases while it was found in higher percentage in a study done in Bangladesh in which abscess was seen in 21.5% and sinus formation in 9.2% of cases. [26] Our study found unilateral neck[ijmyco.org]
Neck Stiffness
  • Cervical lymphadenitis can lead to neck stiffness and torticollis.[emedicine.medscape.com]
  • Cervical lymphadenitis can lead to neck stiffness and torticollis .[emedicine.medscape.com]
  • When it appears in the neck, it can cause pain, neck stiffness and redness of the skin over the lymph nodes. Lymphadenitis also commonly causes of fevers.[livestrong.com]
  • Neck stiffness is a common symptoms with cervical lymph node enlargement and often seen in infectious mononucleosis and cat scratch fever. Preauricular lymphadenitis is common in infections like conjunctivitis, and keratoconjunctivitis.[symptoma.com]
Personality Change
  • Another 17-year-old boy presented with headache for 7 days and behavioral and personality changes. He had a history of cervical lymphadenopathy two weeks ago. CSF analysis demonstrated lymphocytosis, high protein and low glucose ratio.[ncbi.nlm.nih.gov]
Nystagmus
  • She then developed acute encephalopathy, bilateral nystagmus, right hemiparesis and left facial nerve palsy. Her electroencephalogram showed an encephalopathic process and visual evoked response study were grossly abnormal.[ncbi.nlm.nih.gov]
Seizure
  • The next day, he had a seizure. Brain MRI revealed increased signal involving posterior area of both hemisphere. Another 17-year-old boy presented with headache for 7 days and behavioral and personality changes.[ncbi.nlm.nih.gov]

Workup

In children the cervical, inguinal and axillary lymph nodes generally show a swelling up to 12 years of age, after which it reduces in size. The first step towards diagnosis would be take a complete medical history of the patient to check for risk factors. Physical exam up to look for local infections including scalp, ears, nose, upper respiratory tract and chest would help to diagnose underlying cause, if present. A thorough systemic examination is conducted to check for symptoms of malignancy, particularly in the abdominal region. In any case, five factors are important in diagnosis [5]:

  • Size
  • Pain or tenderness
  • Consistency
  • Matting
  • Location

Initial evaluation of the lymphadenitis focuses at the region of primary lymph node enlargement. The second line tests including skin testing for tuberculosis, antinuclear antibody test, hepatitis B serology tests, HIV tests and imaging and are based on specific indications. This is particularly true of persistent generalized lymphadenitis. A number of laboratory studies help in diagnosing the cause of lymphadenitis. Bacterial infections can be diagnosed with the help of Gram staining. The organism can be identified through culture of the specimen. Leukocytosis is indicative of infectious diseases that lead to lymphadenitis. Erythrocyte sedimentation rate, and CRP levels show an increase and are indicative of inflammation

Correct measurements of the enlarged lymph node can be taken using ultrasonography. But this may not be useful in differentiating a malignant lymph node enlargement. Biopsy is suggested if the condition is not related to any local infection or if it has been there for more than four to six weeks. Biopsy is also the procedure if the affected node is supraclavicular or ulcerated. Presence of symptoms like prolonged fever and weight loss calls for a biopsy of the lymph node tissue. To obtain specimen for diagnosis, fine needle aspiration is used except when malignancy is suspected. The affected lymph node is drained after incision if abscesses are found, but this procedure is avoided in the case of lymphadenitis caused by mycobacterial infection, as it may lead to the formation of fistula.

Treponema Pallidum
  • The newly established Treponema pallidum antibody is sensitive to identification of Treponema pallidum in formalin fixed paraffin embedded tissue. 2016 Japanese Society of Pathology and John Wiley & Sons Australia, Ltd.[ncbi.nlm.nih.gov]
Pseudomonas
  • However, it should be noted that the reporting laboratory may be unfamiliar with this bacterium and the isolate may be misidentified as Pseudomonas or even E. coli.[ncbi.nlm.nih.gov]

Treatment

Treatment of lymphadenitis mainly depends on the underlying cause for inflammation of the lymph nodes [6]. Investigation and consultation is required particularly if the inflammation persists for more than six weeks or increase in size [7]. Treatment may include analgesics, antibiotics, chemotherapy or radiation depending on the cause. If the lymph node enlargement is present for two weeks or lesser, and if the size is less than 3 cm, expectant management of the condition is the suggested treatment option. If the nodes are tender and is larger than 2-3 cm, particularly with erythema of the overlying skin, antimicrobial treatment, usually with clindamycin, is recommended [8]. Local guidelines are followed in case of tuberculosis. Chemotherapy and radiotherapy are suggested for malignancies of different types.

In some cases, incision and drainage may be required, particularly for large nodes. Incision is also required for getting aspirate for a diagnostic culture. When the etiology of lymphadenitis is confirmed, the patient may be referred to specialist based on the underlying cause. Further consultations may be with an infectious disease specialist, hematologist, dermatologist, a surgeon or a radiologist, based on the etiology. In most of the cases, the inflammation may resolve when the underlying condition is treated successfully.

Prognosis

Prognosis for this condition depends on the underlying condition that causes lymphadenitis. If lymph node enlargement is caused by malignancies, the condition has a poor prognosis. Other conditions like HIV infection, rheumatoid arthritis and SLE also has increased and prolonged morbidity. Further, the presence of complications like abdominal lymphadenitis may alter the prognosis of the disease condition. But in most of the cases, prognosis is good with early diagnosis and treatment. Treatment with antibiotics aids in reducing infections and improving the prognosis. Those who have elevated risk of infections may have to undergo prolonged antibiotic therapy. Many of them may show recurrence of the infection too. In some cases, the enlargement may resolve within few weeks of prompt treatment, while in some the swelling remain for months.

Etiology

One of the most common causes of lymphadenitis is infections. Apart from infectious conditions, neoplasms and some vascular disorders also may lead to lymph node inflammation [1]. Infectious diseases like cat scratch fever, pharyngitis, toxoplasmosis, shingles, tuberculosis, mononucleosis and scarlet fever are known to cause enlargement of lymph glands. Sexually transmitted diseases that result in lymphadenitis include syphilis, chancroid, hepatitis B, HIV infection, and lymphogranuloma venereum. A number of neoplasms also manifest in the form of lymph node inflammation and includes metastatic melanoma, prostatic cancer, breast cancer, renal carcinoma, Kaposi’s sarcoma, neuroblastoma, and lympholytic and myelocytic leukemia. Other systemic diseases including systemic lupus erythematosus (SLE), and rheumatoid arthritis are also known to cause inflammation of the lymph nodes. Some rare causes of this condition include hyperthyroidism, Gaucher disease, and sarcoidosis.

Regional lymphadenitis often serves as an indicator for further clinical investigation of underlying diseases [2]. Inflammation of supraclavicular lymph nodes point to the presence of lung or gastrointestinal cancer. Axillary node enlargement is common in cat scratch fever, breast cancer, melanoma, brucellosis, and other infectious diseases. Epitrochlear node inflammation frequently occurs in syphilis, lymphoma and sarcoidosis. Inguinal node enlargement is indicative of lymphoma, pelvic malignancy, or sexually transmitted diseases.
In some rare cases, medications are also known to cause lymph node enlargement and include drugs like sulphonamides, atenolol, captopril, penicillin, cephalosporin and hydralazine.

Epidemiology

Reliable population estimates of incidence of this condition are rare. Results of a Dutch study showed that the incidence of this condition in the generalized population is about 0.6%[3]. In this study conducted on 2,556 patients, only 1.1% had malignancy of any form. Unexplained forms of lymphadenitis are rare and found only in 1% of the population with this condition [4]. The risk of cancer is about 4% in people above 40 years with unexplained lymphadenitis. The risk of cancer decreases considerably (0.4%) in people below this age. About three fourth of the all lymphadenitis are localized in nature. In most of the cases, inflammation of the node is caused by a specific pathology in the drainage of lymph in the area. About 25% of the cases requires further investigation for underlying disease to rule out chances of diseases like HIV infection, and tuberculosis.

Sex distribution
Age distribution

Pathophysiology

Under normal conditions lymph nodes show a hyperplastic response to infections as a part of the body’s defense system to prevent diseases. The inflammation may resolve on its own within few weeks once the threat is contained. But in some cases, enlargement may remain, particularly during prolonged or severe forms of infection. Lymph node enlarge in size when an infection is drained into the local lymph gland. The area of involvement of lymph node enlargement will be limited when the underlying disease is localized. In a systemic disease, on the other hand, node involvement will be generalized. Enlargement of the node ensues when lymphocytes, plasma cells or monocytes undergo multiplication within the node. Enlargement is also noted when the node is infiltrated by malignant cells or neutrophils. 

Prevention

The best way to prevent lymphadenitis is prompt diagnosis and treatment of bacterial and viral infections, both of which are common causes of lymph node enlargement [9]. Maintaining good health and general health is equally important in warding off infections of any kind. Avoiding skin injury, insect bites, and scratches on the skin will go a long way in preventing infections and thus lymphadenitis. One should take care to treat skin ulcers promptly and appropriately.

Summary

Lymphadenitis refers to the inflammation of the lymph nodes resulting in swollen and tender lymph glands. Lymph nodes are an integral part of the lymphatic system and are found distributed in clusters throughout the body. These nodes help to trap and filter disease-causing organisms and other abnormal cells from the lymph, thus aiding in fighting infections.

Lymphadenitis is a common symptom in many diseases. Many infections result in localized lymph node enlargement and the common regions where lymph node enlargement is present include cervical, axillary and inguinal lymph glands. Postauricular, supraclavicular and epitrochlear lymph node enlargement is relatively uncommon. Inflammation may be localized or generalized, and affecting a single node or a group of nodes.

Patient Information

Lymphadenitis refers to the inflammation of the lymph nodes present along the lymphatic vessels in the body. These nodes play an important role in fighting infections by filtering disease-causing organisms and other abnormal objects from the lymph. Many bacterial and viral infections result in swelling of the lymph nodes in different parts of the body. In most of the cases, the swollen glands are present near the site of infection. Tumors and some metabolic diseases also result in swollen lymph glands. This condition is often seen after infection by bacteria such as Streptococcus or Staphylococcus.

Lymphadenitis may be seen in any age group. The most common symptom of this condition is the swelling of the lymph nodes which may be tender or hard. The skin covering the node may become tender with or without reddish streaks. Lymphadenitis may be confined to one region or scattered in different parts. If a patient has difficulty in breathing or rapid heartbeat along with swollen lymph glands, it represents a life threatening situation and should seek immediate medical care.

The doctor may start with a complete physical exam and feel the characteristics of the swelling in the lymph nodes. This will help to look out for any signs of infection or injury close to the swollen glands. Biopsy is suggested to check the cause of inflammation. Treatment of lymphadenitis depends on the underlying cause for inflammation. Analgesics may help in controlling pain. If infection is the underlying cause for the swelling, antibiotics are recommended. Swelling can be reduced by anti-inflammatory drugs. Other medications are recommended based on the specific reason that leads to swelling in nodes. If tumors are the cause for swelling, radiation therapy or chemotherapy may be opted. Surgery may be suggested to drain the abscess from the node.

In most of the cases, inflammation of the lymph glands resolve on their own. It may take a few weeks for the swelling to disappear after the treatment. Early diagnosis and treatment are very important in the success of the treatment. But in some cases the swelling may persist and lead to complications.

References

Article

  1. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician. 1998;58(6):1313-1320.
  2. Habermann T, Steensma D. Lymphadenopathy. Mayo Clinic Proc. 2000;75(7):723-732.
  3. Fijten G, Blijham G. Unexplained lymphadenopathy in family practice. An evaluation of the probability of malignant causes and the effectiveness of physicians' workup. J Fam Prac. 1988;27:373-376.
  4. Richner S, Laifer G. Peripheral lymphadenopathy in immunocompetent adults. Swiss Med Wkly. 2010;140(7):98-104.
  5. Morland B. Lymphadenopathy. Arch Dis Child. 1995;73:476-479.
  6. Dulin M, Kennard T, Leach L, Williams R. Management of cervical lymphadenitis in children. Am Fam Physician. 2008;78(9):1097-1098.
  7. Chau I, Kelleher M, Cunningham D. Rapid access multidisciplinary lymph node diagnostic clinic: analysis of 550. Br J Cancer. 2003;88(3):98-104.
  8. Guss J, Kazahaya K. Antibiotic-resistant Staphylococcus aureus in community-acquired pediatric neck abscesses. International Journal of Pediatric Otorhinolaryngology. 2007;71(6):943-948. doi:10.1016/j.ijporl.2007.03.006.
  9. Holme H, Nanduri V. Superior vena cava obstruction: Dangers of a missed diagnosis. Journal of Paediatrics and Child Health. 2011;47(3):150-151. doi:10.1111/j.1440-1754.2010.01741.x.

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Last updated: 2019-07-11 22:16