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Lecture 25
Clinical Approach to Patients with Lymphadenopathy or Splenomegaly
| Question | Answer |
|---|---|
| What type of cells predominant in a primary follicle of a lymph node? | It is composed of virgin(naive) B cells. |
| What type of cells are secondary follicles of the lymph node comprised of? | Mantle zone(rim) of virgin B cells and a germinal center which represents B cells undergoing transformation and differentiation after being stimulated by an antigen. Tcells, macrophages, and follicular dendritic cells are also present. |
| What type of cells is the interfollicular zone of lymph nodes comprised of? | T cells with scattered B cells, macrophages, and interdigitating reticulum cells are present. Cells may be resting, unstimulated cells, or cells at various stages of transformation and differentation of clonted T cells. |
| What is frequently the cause of infarction seen on biopsy of a lymph node? | Malignant disorders |
| What is sinus hyperplasia indicate in a lymph node biospy? | It is the proliferation of sinuses and is a non-specific finding and frequently a normal finding in mesenteric and axillary lymph nodes. |
| What is the appropriate management for lymphadenopathy in an adult with no apparent active infectious process? | Fine needle aspiration of the lymph nodes should be conducted. |
| What is most likely cause of localized or generalized lymphadenopathy in children? | Infectious cause |
| (T or F) FNA of an enlarged lymph node is part of the workup for infectious mononucleosis. | False. Lymph node biopsies are unnecessary and often the histiopathologic interpretatio of these lymph nodes are very difficult. |
| (T or F) A tender, painful lymph node that appears and progresses over a period of a few days or wks are often secondary to an inflammatory process in the area drained by the lymph nodes. | True. |
| What size lymph node is considered enlarged? | A lymph node larger than 1 cm in diameter |
| What would a FNA biopsy of an enlarged, flat, and relatively soft lymph node show? | Biopsy are usually normal or show only hyperplasia. |
| What would a FNA biopsy of a irregular lymph node with rubbery or hard consistency show? | Biopsy would reveal involvement by a malignant neoplastic process. |
| (T or F) If an enlarged lymph node is fluctuant, a needle aspiration should be performed. A biopsy is usually not necessary. | True. |
| What are some disease processes associated with posterior auricular lymphadenopathy? | Rubella, Inflammatory scalp disorders |
| What are some disease processes associated with anterior auricular lymphadenopathy? | Inflammatory disorders of eyelids and conjunctivae, carcinomas |
| What are some disease processes associated with anterior cervical (deep and superficial) lymphadenopathy? | Oral cavity and upper respiratory infecitons, head and neck carcinomas, lymphomas, mucocutaneous lymph node syndrome |
| What are some disease processes associated with submental and submaxillary lymphadenopathy? | Infections and neoplasma of the lips and oral cavity, lymphomas, sinus histiocytosis with massive lymphadenopathy |
| What are some disease processes associated with supraclavicular and scalene lymphadenopathy? | Often involves a malignant process - intrathoracic and intra-abdominal carcinomas, lymphomas, sarcoidosis |
| What are some disease processes associated with axillary lymphadenopathy? | Inflammatory disorders of the upper extremities, lymphomas, carcinomas |
| What are some disease processes associated with epitrochlear lymphadenopathy? | Inflammatory disorders of the upper extremities, non-Hodgkin's lymphomas |
| What are some disease processes associated with mediastinal lymphadenopathy? | lymphomas (hodgkin's disease), thymomas, Castleman's disease |
| What are some disease processes associated with hilar lymphadenopathy? | sarcoidosis (bilateral), carcinomas, lymphomas, pneumoconioses, tuberculosis, fungal infection |
| What are some disease processes associated with retroperitoneal lymphadenopathy? | Usually malignant - lymphomas, carcinomas, sarcomas |
| What are some disease processes associated with mesenteric lymphadenopathy? | non-Hodgkin's lymphomas, carcinomas, nonspecific mesenteric lymphadenitis |
| What are some disease processes associated with inguinal and femoral lymphadenopathy? | Inflammatory disorder of the lower extremities, veneral diseases, lymphomas, melanomas, carcinomas |
| What is the organism responsible for Cat-scratch disease | Bartonella henselae |
| What is the organism responsible for rat-bite fever? | Spirillum minus |
| What is the organism responsible for Talaremia? | Francisella tularensis |
| What is the organism responsible for Anthrax? | Bacillus anthracis |
| What is the organism responsible for Erysipeloid? | Erysipelothrix |
| What is the organism responsible for Bubonic plaque? | Yersinia pestis |
| What is the organism responsible for Lyme disease? | Borrelia burgdorferi |
| What is the organism responsible for Orf? | Pox virus |
| What is the vector for Orf? | Lambs |
| What is the vector for Anthrax? | Cattle, sheep |
| What lymph nodes are characteristically enlarged in Rubella infections? | (1) Posterior auricular (most commonly) (2) Suboccipital (3) Posterior cervical |
| Which lymph nodes is characteristically enlarged in Subacute necrotizing lymphadenitis (Kikuchi's disease)? | Posterior cervical node |
| A benign disorder of children and young adults that is characterized by painless massive bilateral cervical lymphadenopathy along with ever, neutrophilia, and elevated ESR. The lymphadenopathy lasts up to 6 mo to several yrs. | Sinus Histiocytosis with massive lymphadenopathy (Rosai-Dorfman Disease) |
| What is the differential diagnosis for bilateral epitrochlear lymphadenopathy? | (1) secondary syphilis (2) recurrent injury to the hands due to manuel labor (more common) |
| A disorder of young adults characterized by a large solitary mediastinal mass that my compress the bronchus. Histolopathologic features include atypical hyperplasia with "burned out" germinal centers and marked capillary proliferation. | Castleman's disease |
| What is the treatment for localized Castleman's disease? | Surgical resection |
| (T or F) Gonorrhea typically presents with painful inguinal lymphadenopathy. | False. Gonorrhea does not produce lymphadenopathy |
| Definition of generalied lymphadenopathy | Involvement of 2 or more noncontiguous lymph node regions |
| (T or F) Lymph node biopsy is warranted ingeneralized lymphadenopathy | False. It is not necessary in generalized lymphadenopathy. Histopathologic changes would be nonspecific. |
| (T or F) Generalized lymphadenopathy is a cardinal feature of chronic lymphocytic leukemia. | True. |
| Why should biopsy of inguinal lymph nodes be avoided? | The chronic changes (eg scarring) are frequently present in the lymph nodes in the inguinal region. |
| What are the guidelines for selecting a lymph node for biospy if multiple regions are affected? | The largest lymph nodes should be selected. Certain regions should be avoided if possible (eg inguinal, femoral, epitrochlear). |
| What are Billroth's cords? | Splenic cords which are extravascular collections of hematopoietic cells, mostly red cells. |
| What percentage of the cardiac output is utilized by the spleen? | 5% |
| Pathophysiology of splenomegaly secondary to chronic passive congestion | Venous blood flows from spleen via portal vein through the liver back to the systemic circulation. The spleen is enlarged due to any obstruction of the splenic or portal veins, liver disease, or chronic increase in systemic venous pressure. |
| What percentage of red blood cells are normally sequestered in the spleen? | <1% |
| What percentage of granulocytes are normally sequestered in the spleen? | 20% |
| What percentage of platelets are normally sequestered in the spleen? | 30% |
| Where does the final maturation step of reticulocytes occur? | Splenic cords |
| In thrombocytopenia secondary to splenic sequestration, up to what percentage of platelets can be pooled in the spleen? | Up to 90% of platelet cell mass |
| What type of granulocyte is mainly sequestered in normal spleen? | Neutropenia |
| (T or F) Lymphocytosis and thrombocytosis typically occurs post-splenectomy | True. |
| What is the normal size of a spleen? | 4 x 8 x 12 cm |
| What is the normal weight for a spleen? | Less than or equal to 200 grams |
| How can an enlarged spleen be differentiated from a retroperitoneal mass or other enlarged organs with deep palpation? | The spleen moves downward during inspiration whereas other retroperitoneal masses and other enlarged organs do not move downward on deep inspiration. |
| (T or F) A normal size spleen can be usually palpable in most neonates. | True. |
| What age groups can a normal sized spleen be palpated on physical exam? | 10% of children, most neonates, and 30% of full-term infants |
| What are the clinicl manifestations of splenomegaly | 1) LUQ pain 2) Left supraclavicular pain 3) Early saiety 4) Weight loss 5) Excess sweating 6) Manifestations of cytopenia 7) Hematemesis from varices |
| What are the mechanisms of cytopenias in splenomegaly? | (1) Increased rate of cell destruction (2) Sequestration or pooling of circulating blood cells (3) Diluation of the peripheral red cell mass due to plasma volume expansion |
| What is the most common cause of splenomegaly in teenagers and young adults? | Infectious mononucleosis |
| Clinical manifestations of the Big Spleen Syndrome | 1)Portal hypertension 2)Expanded anatomic vascular space 3)Expanded plasma vol/total blood vol 4)Cytopenia 5)Hypermetabolism 6)Inc CO 7)Wide pulse pressure 8)Dec systemic peripheral resistance 9)Na/Water retention 10)Inc rate of albumin synthesis |
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