Conditions of the Lymph System

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Conditions of the Lymph System
Part A Module A2 Session 6
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Objectives

• Describe the various etiologies that cause
  lymphadenopathy
• Describe the clinical presentation of persistent
  generalized lymphadenopathy (PGL)
• List the diagnostic criteria for PGL
• Describe features of lymph nodes that indicate
  further evaluation
• Make a differential diagnosis using a case study
  approach

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Overview

• Swelling of lymph nodes is a frequently
  encountered symptom
• It is important to carry out a careful history
  and physical exam
• The cause often becomes obvious, but in more
  complicated cases, laboratory tests and lymph
  node biopsy may be necessary to establish a
  definitive diagnosis

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Major Pathogens

• HIV- related persistent generalized
  lymphadenopathy (PGL)
• Opportunistic infections tuberculous
  lymphadenitis, CMV, toxoplasmosis,
  infections with Nocardia species, fungal
  infections (histoplasmosis, penicilliosis,
  cryptococcus, etc.)
• Reactive Lymphadenopathy pyomyositis, pyogenic
  skin infections, ear, nose, and throat (ENT)
  infections
• STIs syphilis, inguinal lymphadenopathy due
  to donovanosis, chancroid or
  lymphogranuloma venereum (LGV) (see WHO
  or MSF guidelines)
• Malignancies lymphoma, Kaposis sarcoma

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Chart 4. Conditions of the Lymph System
Lymphadenopathy
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Persistent Generalized Lymphadenopathy (PGL)
Presenting Signs and Symptoms

• Lymph nodes larger than 1.5 cm in diameter in 2
  or more extrainguinal sites of 3 or more months
  duration
• Nodes are non-tender, symmetrical, and often
  involve the posterior cervical, axillary,
  occipital, and epitrochlear nodes

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Diagnostics

• Where possible, do a CBC (FBC) and chest x-ray
  before making a diagnosis of PGL
•  Hilar or mediastinal lymphadenopathy on CXR

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Management and Treatment

• No specific treatment for PGL

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Unique features, Caveats

• Develops in up to 50 of HIV-infected individuals
  
• Up to one-third do not have any other symptom on
  presentation (WHO clinical stage 1)
• In HIV-positive patients, PGL is a clinical
  diagnosis. No further examinations are necessary,
  unless there are features of another disease
•  PGL may slowly regress during the course of HIV
  infection and may disappear before the onset of
  AIDS

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Tuberculosis lymphadenopathy
Presenting Signs and Symptoms

• Cervical nodes most commonly involved
• Usual course of lymph node disease is as follows
• Firm, discrete nodes
• ?
• fluctuant nodes matted together
• ?
• skin breakdown, abscesses, chronic sinuses
• ?
• healing and scarring

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Diagnostics

• Fine-needle aspiration of the involved lymph node
•  
• Extra-thoracic lymph node aspiration
•  
• Positive smears for acid-fast bacilli on
  fine-needle aspirates of the involved lymph nodes
  (high rate in HIV patients)
•  
• In smear-negative pulmonary TB, it is worthwhile
  aspirating extra-thoracic lymph nodes to confirm
  diagnosis of TB (80 positive)

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TB abscess as part of immune reconstitution
syndrome
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Management and Treatment

• Treatment should be started following the
  national TB Guidelines.
• For further details, see Part A Module 2, Session
  3.

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Unique features, Caveats

• One of the most common forms of extra-pulmonary
  TB in HIV patients
• Fluctuant cervical nodes that develop over weeks
  to months without significant inflammation or
  tenderness suggest infection with M.
  tuberculosis, atypical mycobacteria, or scratch
  disease (Bartonella henselae).
• In severe immunocompromised patients,
  tuberculosis lymphadenopathy may be acute and
  resemble acute pyogenic lymphadenitis
• Miliary TB is an important consideration in
  patients with generalized lymphadenopathy

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Nocardiosis

• Presenting Signs and Symptoms
• Clinical Symptoms may evolve
• Chronic lymphadenopathy
• Abscesses (skin, pulmonary, etc.)

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Diagnostics

• Fine-needle aspiration of the involved lymph node
• Organism may stain weakly on acid-fast staining.
  The organisms are different from the Koch bacilli
  because of their thread-like filaments
• Nocardia organisms are easily recognized on Gram
  stain

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Management and Treatment

• TMP/SMX 10/50 mg/kg bid or minocycline 100 mg bid
  combined with amikacin 15-25 mg/kg daily
• or
• ceftriaxone 2 gm daily combined with amikacin.
• The use of aminoglysides should be limited to 2
  weeks

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Unique features, Caveats

• While norcardiosis is a rare cause of
  lymphadenitis in immune-competent patients, the
  diagnosis should be considered in HIV-infected
  patients with chronic lymphadenopathy and
  abscesses (skin, pulmonary, etc.)

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Fungal infections (histoplasmosis,
penicilliosis, cryptococcosis)

• Clinical Symptoms may evolve
• Fever
• Lymphadenopathy
• Often skin lesions or lung lesions

Presenting Signs and Symptoms
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Diagnostics

• Biopsy for histology and culture of skin lesions
  or lymph nodes often reveals the diagnosis

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Management and Treatment

• Initial treatment for histoplasmosis and
  penicillinosis
• amphotericin B for moderate-to-severe cases
• Itraconazole 200 mg daily is the preferred
  lifelong maintenance therapy
• If itraconazole is not available, use
  ketaconazole 400 mg daily
• For cryptococcosis give
• amphotericin B (IV) o.7 mg/kg daily for 14 days,
  followed by fluconazole 400 mg daily for 8-10
  weeks.
• After that, maintenance therapy consists of
  fluconazole 200 mg once a day

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Secondary syphilis
Presenting Signs and Symptoms

• Clinical Symptoms may evolve
• Generalized painless lymphadenopathy
• Maculo-papular, papular, or pustular rash on
  entire body, especially on palms and soles
• Highly infectious lesions on mucous membranes
  (lips, mouth, pharynx, vulva, glans penis) which
  are silvery grey superficial erosions with a red
  halo and not painful unless there is a secondary
  infection.
• 40 of these patients will have CNS involvement
  with headache and meningismus
• 1-2 will develop acute aseptic meningitis

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Diagnostics

• CSF exam 
• CSF shows increased protein and lymphocytic
  pleocytosis

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Management and Treatment

• Although there is some doubt about treatment
  efficacy in HIV patients, the CDC recommends the
  same treatment for primary and secondary syphilis
  as in HIV-negative individuals
• benzathine penicillin 2.4 million units IM single
  dose
• In case of penicillin allergy, give
• doxycycline 100 mg PO bid for 21 days
• or
• ceftriaxone 1 gm IM/IV daily for 14 days

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Lymphoma and Kaposis Sarcoma

• Presenting Signs and Symptoms
• Clinical Symptoms may evolve
• Lymphadenopathy
• Characteristic skin lesions in oral cavity, GI
  tract, and respiratory tract

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Diagnostics

• Diagnosis confirmed by histopathology

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Management and Treatment

• For treatment and management, see Part One,
  Module 2/ Session 11

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Thank You