Evaluation of Lymphadenopathy &Splenomegaly

Daniel Eshetu

Lymphatic system Introduction Mechanism and causes of lymphadenopathy Approach to lymphadenopathy: Hx, P/E, Lab

Splenomegaly Introduction Causes of splenomegaly Evaluation of splenomegaly: Hx, P/E, Lab studies,

Imaging... Evaluation of swellings (Lumps)

Lymphatic/ lymphoid system comprises the lymph, the lymphatic vessels, lymph nodes, the thymus and the spleen.

Function of the lymphatic system

it is responsible for the removal of interstitial fluid from tissues

it absorbs and transports fatty acids and fats as chyle from the digestive system

it transports white blood cells to and from the lymph nodes into the bones

The lymph transports antigen-presenting cells (APCs), such as dendritic cells, to the lymph nodes where an immune response is stimulated

Diagnostic dilemma Various causes with spectrum of clinical

course Localized or Generalized Normal size of LNs

Larger in adolescents Inguinal and submandibular

Recurrent trauma and infection

Benign proliferation of residential cells HIV Infection

Infiltration by inflammatory cells Infection – lymphadenitis Auto-immune conditions- SLE

In situ proliferation of Malignant lymphocytes Lymphomas

Infiltration of lymph nodes by metastatic malignant cells Breast cancer Colorectal cancer Lung cancer

Infiltration of lymph nodes by metabolite-laden macrophages: Lipid storage diseases

Infectious Viral Bacterial Fungal Chlamydial Parasitic Rickettsial

Immunologic diseases Malignant diseases

Hematologic Metastatic

Lipid storage diseases Endocrine diseases Other disorders

Focused history Sx of anemia Infection Bleeding

Duration of lymphadenopathy Acute vs Chronic

Progression of the lymphadenopathy Waxing & weaning Slow vs fast Involvement of adjacent or distant LN

Associated symptoms Pain Fever, hotness Sx of obstruction

Localizing symptoms of infections and malignancy Draining sinus Hotness and local pain

Exposures Radiation Chemotherapy Other agents: pets

Constitutional symptoms Travel history

Endemic areas Medications associated with LAP

Anticonvulsants Drugs which cause LAP with serum sickness

Complete physical examination is vital Distribution

Localized Regional generalized

Symmetry

Features characteristic of the lymph node Location Size Consistency Fixation Tenderness

Splenomegaly hepatomegaly

• Components– Various laboratory and serologic tests– Imaging– Lymph node biopsy– Bone Marrow study – Other biopsies. – ? Empirical treatment

• Depend on various factors– Age– Duration– Localized/regional/generalized– Epidemiology and the clinical setting

Laboratory tests CBC & Peripheral Smear ESR HIV RPR/VDRL ANA Heterophile Antibody tests LDH & other tests according to the setting as

well as importance

Imaging study for the purpose of Defining size & distribution more precisely Distinguishing from other similar structure Staging Guiding for FNA

Imaging study includes Chest X-Ray Ultrasonography & Doppler Nuclear/Isotope scans CT-Scan MRI PET/SPECT

• Types of biopsy– Open biopsy– Fine Needle Aspiration– Core Needle Biopsy

• Choice of LN & type of biopsy– The most diseased– Supraclavicular/cervical/axillary/inguinal– If single go for open biopsy as much as possible– accessability

• Possible studies from the specimen– Pathological– Immunochemistry/immunophenotype– Genetic/molecular studies

Spleen is one of the lymphoid organs which is also called reticuloendothelial system.

Splenomegaly is common clinical condition & it is never normal

Various causes with diagnostic challenge Other condition

Massive splenomegaly Splenic infarction Ruptured spleen Splenic abscess Functional hyposplenism/ asplenia Hypersplenism

Lies in the Peritoneal cavity in the left upper quadrant.

Adjacent to 9th- 11th rib, stomach, colon and pancreas.

Weight Male= 80-200g Female= 70-180g Average = 150g (0.2% of Body Weight)

Palpability and size Not palpable normal ( children, adolescents, thin

adults) Soft organ unless infiltrated

Participates in cellular and humoral immunity Removes senescent and/or poorly deformable

red cells, bacteria, and other particulates from the circulation

Under abnormal circumstances the spleen may become the site of extramedullary hematopoiesis

Approximately one-third of circulating platelets are sequestered in the spleen, where they are in equilibrium with circulating platelets

Splenic abnormalities can include Increased function (hypersplenism) Decreased to absent function (hyposplenism,

asplenia) Abscess, infarction, calcification, cysts Traumatic or atraumatic rupture Enlargement (Splenomegaly)

Splenic engorgement with sequestration Chronic inflammation or infection Lipid deposition Congenital condition Splenic infiltration

1.Congestive Cirrhosis Heart Failure Thrombosis of portal, hepatic and splenic veins

2.Malignancy Lymphomas, usually indolent Leukemias Myeloproliferative Disorders Primary splenic tumours Metastatic solid tumours

3. Infections Viral - hepatitis, infectious mononucleosis,

cytomegalovirus Bacterial - salmonella, brucella, tuberculosis Parasitic - malaria,

schistosomiasis,toxoplasmosis, leishmaniasis Infective endocarditis Fungal

4.Inflammation Sarcoid Serum sickness Systemic lupus erythematosus Rheumatoid arthritis (Felty syndrome)

5.Infiltrative ( Non-Malignant) Gaucher’s Glycogen storage disease Amyloidosis

6.Hematological ( Hypersplenic) states Acute and chronic hemolytic anemias, all etiologies Sickle cell disease (children) Following use of recombinant human granulocyte

colony-stimulating factor

Definition – splenomegaly >8cm BLCM Causes

Chronic myeloid leukemia Myelofibrosis, idiopathic or post-polycythemic Gaucher disease Lymphoma, usually indolent Hairy cell leukemia Kala-azar (visceral leishmaniasis) Hyperreactive malarial splenomegaly

syndrome(tropical splenomegaly syndrome ) Thalassemia major AIDS with Mycobacterium avium complex

History Physical Examination Laboratory studies Imaging Additional studies

Biopsy

Symptoms of splenomegaly Pain, a sense of fullness, or discomfort in the left

upper quadrant Pain referred to the left shoulder Early satiety, due to encroachment on the

adjacent stomach Focused history Underlying conditions Constitutional symptoms Travel history

Complete physical examination Cardinal steps in spleen/ abdominal exam

Inspection Palpation

Bimanual Ballottement Middleton’s method ( palpation from above)

Percussion Nixon’s Method Castell’s Method Percussion of the Traube’s semilunar space

Auscultation

CBC & Peripheral Smear ESR HIV RPR/VDRL ANA, RF Heterophile Antibody tests LDH & other tests according to the setting as well as

importance

Spleen CT scanning magnetic resonance imaging ultrasound Tc-99m sulfur colloid scintigraphy 18F-FDG PET

Other sites CXR CHEST CT

Splenic Biopsy Aspiration Following splenectomy Laparascopy

Liver biopsy Bone Marrow Aspiration/Bone Marrow

Biopsy Biopsy from other sites

• If there is an unusual lump anywhere in the body note the following– Site/appearance– Size in diameter– Shape & nature of surface skin– Fixation– Consistency– Tenderness– Pulsation & bruit(auscultation)– Transillumination in a darkened room

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