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H12 Hematology
Approach to Lymphadenopathy Toronto Notes 2019 Leukemoid Reaction
• bloodfindingsresemblingthoseseenincertaintypesofleukemiawhichreflecttheresponseofhealthy BM to cytokines released due to infection or trauma
• leukocytosis>50x109/L,markedleftshift(myelocytes,metamyelocytes,andbandsinperipheralblood smear)
Approach to Lymphadenopathy
History
• constitutional/B-symptoms:seeninTB,lymphoma,othermalignancies
• growthpattern:acutevs.chronic
• exposures:cats(catscratch–Bartonellahenselae),ticks(Lymedisease–Borreliaburgdorferi),andhigh
risk behaviours (HIV)
• jointpain/swelling,rashes(connectivetissuedisorder)
• pruritus (seen in Hodgkin lymphoma)
• medications (can cause serum sickness → lymphadenopathy)
Clinical Features
• determineiflymphadenopathyislocalizedorgeneralized • localized:typicallyreactiveorneoplastic
■ cervical (bacterial/mycobacterial infections, ENT malignancies, and metastatic cancer) ■ supraclavicular
◆ right (mediastinal, bronchogenic, esophageal cancer)
◆ left (gastric, gall bladder, pancreas, renal, and testicular/ovarian cancer) ■ axillary (cat scratch fever, breast cancer, and metastatic cancer)
■ epitrochlear (infections, sarcoidosis, and lymphoma)
■ check for splenomegaly, constitutional symptoms
Investigations
• CBCanddifferential,bloodfilm
• if generalized, consider tuberculin test, HIV RNA, VDRL, Monospot®/EBV serology, ANA, and imaging • iflocalizedandnosymptomssuggestiveofmalignancy,canobserve3-4wk(ifnoresolution→biopsy) • excisionalbiopsyispreferredasitpreservesnodearchitecture(essentialfordiagnosinglymphoma)
• inareasdifficulttoaccess(retroperitoneal,mediastinal/hilar)multiplecorebiopsiesmaybemore
practical/feasible
• FNA should NOT be used for diagnostic purposes in lymphoproliferative disease (use excisional biopsy
instead)
■ FNA is helpful for recurrence of solid tumour malignancy
■ imaging such as U/S or CT can provide more info, but generally adds little to diagnosis
Constitutional/B-Symptoms
• Unexplained temperature >38°C
• Unexplained weight loss (>10% of body
weight in 6 mo)
• Night sweats
Drugs that can cause Lymphadenopathy
• Allopurinol
• Atenolol
• Captopril
• Carbamazepine • Cephalosporins • Gold
• Hydralazine
• Penicillin
• Phenytoin
• Primidone
• Pyrimethamine • Quinidine
• Sulfonamides • Sulindac
Table 7. Inflammatory vs. Neoplastic Lymph Nodes
Feature
Consistency Mobility Tenderness Size
Inflammatory
Rubbery Mobile Tender <2 cm
Neoplastic
Firm/hard Matted/immobile Non-tender
>2 cm
*Note: these classifications are not absolute; lymphoma and CLL nodes can feel rubbery and are frequently mobile, non-tender
Table 8. Differential Diagnosis of Generalized Lymphadenopathy
Reactive
Bacterial (TB, Lyme, brucellosis, cat scratch disease, and syphilis)
Viral (EBV, CMV, HIV) Parasitic (toxoplasmosis) Fungal (histoplasmosis)
Inflammatory
Collagen disease (RA, dermatomyositis, SLE, vasculitis, and Sjögren’s)
Drug hypersensitivity Sarcoidosis, amyloidosis Serum sickness
Neoplastic
Lymphoproliferative disorder/ lymphoma
Metastatic cancer Histiocytosis X