Lymphatics And Lymph Node Enlargement Important Question And Answers

Lymphatics And Lymph Node Enlargement

• Bacterial as: Streptococcus, Mycobacterium, Treponema pallidum, Actinomycosis.
• Viral as: Lymphogranuloma venereum, Infectious mononucleosis, HIV
• Parasite as: Wuchereria bancrofti
• Fungus as: Blastomycosis.

• Systemic lupus erythematous
• Rheumatoid arthritis
• Sclerosis.

• Malignant lymphoma
• Hodgkin’s disease
• Lymphosarcoma
• Malignant melanoma.

• Swelling in the neck is present, which is fim and mattd.
• Cold abscess is soft, smooth, non-tender, flctuant, without involvement of the skin. It is not warm.
• As a result of increased pressure, cold abscess ruptures out of the deep fascia to form collar stud abscess which is adherent to the overlying skin.
• Once collar stud abscess bursts open, discharging sinus is formed. It can be multiple, wide open mouth, often undermined, non-mobile with bluish color around the edge. It is usually not indurated.
• Tonsils may be studded with tubercles and so clinically should always be examined.
• Associated pulmonary tuberculosis should also be looked for. In 20% cases of tuberculous lymphadenitis, there may be associated pulmonary tuberculosis or it may be a primary focus.
• Cervical spine is examined for tuberculosis.
• Axillary nodes, when involved are due to retrograde lymphatic spread from neck nodes or blood spread.
• Inguinal lymph nodes are involved occasionally through blood.
• Bluish hyperpigmented involved overlying skin is called as scrofuloderma.
• Tuberculous pus with caseating cheesy creamy material is infective as it contains multiplying organisms.
• Atypical mycobacterial tuberculosis can occur occasionally.
• Such disease may be resistant to drug therapy.
• Sinus may persist due to firosis, calcifiation, secondary infection inadequate reach of drug tomaintain optimum concentration in caseation

• Rifampicin 450 mg OD on empty stomach. It is bactericidal.
• INH: 300 mg OD. It is bactericidal.
• Ethambutol 800 mg OD. It is bacteriostatic.
• Pyrazinamide 1500 mg OD (or 750 mg BD). It is bactericidal.

• There is no local response to drugs
• When sinus persists.

• Tuberculous bacillus, i.e. Mycobacterium tuberculosis is the bacteria which leads to tuberculosis.
• Disease is caused in people of low socioeconomic status, unhygienic living conditions and malnutrition.
• In 20% of cases, lymph nodes are affcted in posterior triangle due to involvement of adenoid.

• The initial response of neutrophils
• There is progressive infitration by macrophages
• Macrophages start phagocytosing the tubercle bacilli.
• Activated CD4 + T-cells develop.
• In 2 to 3 days, the macrophages undergo structural changes and form epithelioid cells.
• The epithelioid cells aggregated into tight clusters or granulomas.
• Some macrophages form multinucleated giant cells.
• Hard tubercles form by the mass of epithelioid cells and the giant cells in a zone of lymphocytes,plasma cells and firoblasts.
• Center of the cellular mass undergoes caseous necrosis,characterized by cheesy appearance called as soft tubercle.

• Common in young adult between 20–30 years.
• Upper anterior deep cervical nodes are enlarged.
• Non-tender, discrete, mobile, fim lymph node is palpable.

• Results due to involvement of capsule of lymph node.
• Nodes moves together
• Firm, non-tender.

• It occurs due to caseation necrosis of lymph node.
• No local rise in temperature.
• No tenderness.
• No redness.
• Soft, cystic and flctuant swelling.
• Transillumination is negative.
• On sternomastoid contraction test, it becomes less prominent indicating that it is deep-to-deep fascia.

It results when a cold abscess rupture through the deep fascia and form another swelling in the subcutaneous plane which is flctuant.

Stage of Sinus

• Collar stud abscess burst and form tubercular sinus.
• Common in young female.
• It can be multiple.
• Resemble an ulcer with undermined edge.
• No indurations.
• Skin surrounding the sinus shows pigmentation and sometimes bluish in color.

• Non-specific lymphadenitis
• Secondaries in neck
• Lymphomas and chronic lymphatic leukemia
• Branchial cyst and lymphatic cyst mimic cold abscess
• HIV with lymph node involvement

• Hematocrit, ESR, peripheral smear.
• FNAC oflymph node and smear forAFB and culture: FNAC is very useful but not as superior as open node biopsy.
  False negative, false positive results and altering the node architecture, and so eventual need of open biopsy are the problems.
  Epithelioid cells (modifid histiocytes/macrophages) are diagnostic.
  Langhans giant cells, lymphocytes, plasma cells are other features.
• Open biopsy: Open biopsy is more reliable for tuberculosis (and also in lymphoma; but it is contraindicated in node secondaries); entire node ideally two nodes if possible has to be taken intact; one in formalin for pathology, other in normal saline for microbiology (AFB).
• HIV test (ELISA and western blot).
• Lowenstein-Jensen media is used for culture which takes 6 weeks to give result; so selenite media is often used which shows growth in 5 days.
• Mantoux test may be useful; but not very reliable.
• Chest X-ray to look for pulmonary tuberculosis.
• Polymerase chain reaction (PCR) is very useful method.

• It is bilocular abscess with one lobule deep to the deep fascia and another lobule is superfiial to fascia.
  Both the locule intercommunicates with each other through a small perforation in the deep fascia.
  Such an abscess can occur anywhere in the body.

• Pyogenic: When pyogenic abscess develops deep to deep fascia and gradually pressure mouth so that the deep fascia perforates, the pus comes out into superfiial fascia.
  So, pyogenic collar stud abscess is more commonly seen in hand where deep fascia is in the palmer fascia.
• Tuberculous: This is more often seen in the neck from caseation tubercular lymph node.
  The cold abscess beneath the deep fascia ruptures and forms another swelling in subcutaneous plane which is fluctuant. It remains adhere to skin.

• Drainage ofterminal pulp space byanoblique deep incision.
• Systemic antibiotics should be given.

• Anti-tubercular treatment is given.
• Zig-zag aspiration by wide bore needle in non-dependent area for prevention of sinus perforation.
• Drainage can be done by using non-dependent incision and later on closure of wound is done without placing a drain

 

• Acute infection process: Glandular fever.
• Tuberculosis
• Syphilis: In secondary stage
• Disseminated lupus erythematosus
• Blood disease: Acute lymphatic leukemia, chronic lymphatic leukemia
• Neoplasm: Secondary carcinoma
• HIV infection and AIDS
• Sarcoidosis.

• Mainly radiotherapy, i.e. external high cobalt radiotherapy
• Above the diaphragm: Y-fild therapy, covering cervical,axillary, mediastinal lymph nodes.
• Below the diaphragm: Mantle or inverted-Y fild therapy covering para-aortic and iliac nodes.
• Chemotherapy is also given.

• In this, mainly chemotherapy is given.
• Regimens used are:

• Mechlorethamine: 6 mg/sqm on 1st and 8th day
• Oncovine: 1.4 mg/sqm on 1st and 10th day
• Procarbazine: 100 mg orally daily for 10 days
• Prednisolone: 45 mg orally daily for 10 days

• Adriamycin: 30 mg/sqm
• Bleomycin: 10 mg/sqm
• Vinblastine: 6 mg/sqm
• Dacarbazine: 350 mg/sqm
  The cycle is repeated on 20th day.
  Splenectomy is done in many patients except with stage IV disease.

• Tuberculous lymphadenitis: Cold abscess is seen commonly in anterior triangle of neck
• Tuberculosis ofcervical spine: Cold abscess is seen commonly in posterior triangle of neck.

• It is commonly seen in young individuals but can occur in any age group.
• Swelling in neck is smooth, non-tender, soft, flctuating,non-transilluminant, non-mobile and is notadherentto skin.
• There is presence of neck pain, neck rigidity and restricted movements of cervical spine.
• Rust sign: With change in position and often when patient is seated, he support his head with hands and forearm.
• There is presence of evening fever, loss of weight and appetite.
• Mattd lymph nodes adjacent to cold abscess should be palpable.

• Oral cavity, chest and tonsils of the patient are thoroughly examined.
• ESR is raised
• Mantoux test is positive. This test is useful but not reliable.
• Presence of anemia and lymphocytosis
• Chest X-ray show pulmonary tuberculosis
• FNAC of cold abscess under microscopic examination show epithelioid cells.
• Fluid obtained by FNAC should be stained by ZiehlNeelsen stain which reveals acid-fast bacilli
• X-ray neck is done in cervical spine tuberculosis to identify reduced joint space, vertebral destruction, soft tissue shadow.
• MRI of cervical spine, ultrasonography or CT scan neck are needed to confim anatomical location and number of lesions.

• Anti-tubercular treatment is given to the patient.
• Non-dependent aspiration of cold abscess.
• Diseased neck nodes should be excised.
• Immobilization of cervical spine by plaster jacket/collar for 4 months.
  Cervical spine fusion by open surgical method,if diseased spine is unstable.

• Most commonly lower limb is involved.
• Presence of swelling in the foot which extends progres sively in the neck and show tree-trunk pattrn leg.
• Presence of bufflo hump in dorsum of foot.
• Athlete’s foot with joint pain and disability
• Fever, malaise and headache
• Initially pitting edema occurs which later on become
• Non-Pittng.
• Stemmer’s sign is positive, i.e. skin over dorsum of foot cannot be pinched because of subcutaneous firosis.

• Latent: No clinically apparent lymphoedema
• Grade I: Pittng edema which more or less disappears on elevation of the limb.
• Grade II: Non-pittng edema occur which does not reduce on elevation
• Grade III: Edema with irreversible skin changes like firosis,papillae, fisuring.

• Elevation of limb, exercise and weight reduction.
• Static isometric activities should be stopped such as prolong standing or carrying heavy weight.
  Rhythmic movements should be encouraged such as swimming,massaging
• Daily wearing of below-knee stockings
• Trauma and infection should be avoided.
• Complex decongestive therapy should be given.
  It occurs in two phases, i.e. intensive therapy and maintenance therapy.

• Excision of lesion can be done by Charle’s or Homan’s operation.
• Physiological: Omentoplasty can be done.
• Combination ofExcision and physiological: Both excision and creation of communication between superfiial and deep lymphatics. Sistrunk and Thompson’s operation can be done.
• Bypass procedures can be done
• Limb reduction surgeries can be done.

• Seen commonly in middle-aged and older individuals.
• Patient complains of episodes of fever with chills with evening rise of temperature. Patient becomes tired early.
• Presence of gradual loss of weight.
• Patient has persistent cough with or without hemoptysis.
• Swelling on neck is present which is fim and tender on palpation. When abscess is formed swelling perforates and pus drains out.
• Scrofula is the condition in which there is marked enlargement of cervical lymph nodes with caseation
• necrosis and frequent breakdown of gland.
• As skin is involved by tuberculosis, this is known as lupus vulgaris.
• Tubercular involvement of spine is called as Potts disease.
• When tuberculosis spreads through bloodstream it involves organs such as liver, kidney the disease is known as miliary tuberculosis.

• Directly observed treatment strategy adopted by WHO is followed all over the World including India.
• Directly observed treatment means that an observer watches the patient swallowing their tablets.
• DOT ensures accountability of TB services and helps to prevent emergence of drug resistance.

• Political and administrative commitment at all levels.
• Diagnosis through sputum microscopy
• Uninterrupted supply of short-course chemotherapy drugs.
• Direct observation of drug intake (DOTS)
• Systematic monitoring, evaluation, and supervision at all levels.

• Tuberculosis
• Syphilis.

• Pericoronitis
• Periodontal disease
• Peri-apical infections.

• Infection mononucleosis
• AIDS
• Herpes simplex
• Cat scratch disease.

• Oral candidiasis
• Histoplasmosis.

• Rickettsial Infection.

• Serum sickness.

• Lymphoma.

• Oral squamous cell carcinoma
• Metastasis of carcinoma of breast.

• Leukemia
• Collagen diseases
• Sarcoidosis
• Non-tender lymphoid hyperplasia.

• The initial response of neutrophils
• There is progressive infitration by macrophages
• Macrophages start phagocytosing the tubercle bacilli
• Activated CD4 + T cells develop
• In 2 to 3 days, the macrophages undergo structural changes and form epithelioid cells
• The epithelioid cells aggregated into tight clusters or granulomas
• Some macrophages form multinucleated giant cells
• Hard tubercles form by the mass of epithelioid cells and the giant cells in a zone of lymphocytes, plasma cells and firoblasts
• Center of the cellular mass undergoes caseous necrosis,characterized by cheesy appearance called as soft tubercle.

• It is commonly associated with cellulitis.
• Erysipelas is a type of lymphangitis.
• In endemic areas, fiariasis is the most common cause (coastal India). It is caused by Wulchereria Bancroft.

• Streaky redness which is spreading is typical.
• On pressure, area blanches; on release redness reappears.
• Edema of the part, palpable tender regional lymph nodes are obvious.
• Fever, tachycardia, features of toxemia.
• Groin lymph nodes are enlarged and tender in lower limb lymphangitis.
• In upper limb, as lymphatics are mainly located on the dorsum of hand, edema and redness develops on the
• dorsum. Infection in thumb and index finger causes palpable tender axillary nodes; in litte and ring figer
• causes fist tender palpable epitrochlear nodes to appear; infection in middle figer causes fist deltopectoral nodes to enlarge.
• Toxemia, septicamia may occur.
• Rapidity may be more indiabetics and immunosuppressed.
• Chronic lymphangitis occurs due to repeated attacks of acute recurrent lymphangitis leading into acquired lymphoedema.

• Blood cell count
• Platelet count
• Renal and liver function tests
• Peripheral smear and blood culture

• Antibiotics such as penicillin, cloxacillin.
• Elevation, rest, glycerine magnesium sulpha dressing.
• Management of toxemia or septicemia with critical care.

• In a situation, where a self-limited infection is thought to be the etiology ofacute cervical lymphadenitis, it is reasonable to observe and provide reassurance.
• Unilateral lymphadenopathy that has a history of a rapid onset and overlying erythema of the skin and is accompanied by a fever suggests a bacterial infection. In this case, oral antibiotic therapy for 10–14 days and close follow-up is the appropriate management.
• An ultrasound may be indicated to evaluate for the presence and extent of suppuration.If confimed surgical drainage is required with the presence of a flctuant mass,suggesting an abscess.
• On follow-up of adenopathy, further evaluation should be considered, if there is not a decrease in size after 2 weeks.
• Laboratory evaluation may include the following: CBC with differential, ESR, titers for Ebstein-Barr virus/cytomegalovirus/toxoplasmosis/cat-scratch disease,antistreptolysin O or anti-DNAase serologic tests, PPD,and chest radiograph.
• Non-infectious causes of cervical lymphadenopathy include Kawasaki Disease, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervicaladenitis), and Sarcoidosis. Cervical lymphadenopathy is accompanied by a number of other signs and symptoms in each of these non-infectious disorders, and evaluation and management is individualized based on the disease.

• Laboratory evaluation includes CBC, ESR, PPD, B henselae serology, and titers for Ebstein-Barr virus/cytomegalovirus/toxoplasma among other tests based on history and physical examination.
• Children who have chronic cervical lymphadenopathy often undergo extensive diagnostic evaluation before an etiology is determined.
• Special attntion should be given to the possibility of TB and HIV disease; the hematologic and serologic testing noted previously can be helpful.
• Urine antigen tests for Histoplasma capsulatum occasionally can be helpful.
• If there is an increase in lymph node size over 2 weeks,lack of decrease in size over 4–6 weeks, lack of regression to normal within 8–12 weeks, or the presence of persistent fever, weight loss, fatigue, night sweats, hard nodes, or fiation of nodes to surrounding tissues, a biopsy should be performed for further evaluation.
• Biopsy can be in the form of open biopsy or fie needle aspiration to further investigate for certain pathology,including infectious and non-infectious causes, specifically malignancy. Because lymphadenitis caused by nontuberculous Mycobacterium (NTM) evolves to draining skin fitulas associated with scarring, the safety of needle aspiration when this infection is suspected has been questioned.

• Needle aspiration may not lead to increased risk for this complication because the treatment of a node found to be infected with NTM is surgical excision-a cure for skin fistulas.
• NTM and Bartonella infection are diagnosed best using material obtained from a suppurative lymph node, which can be stained and cultured for acid-fast organisms and sent for polymerase chain reaction (PCR) examination to detect B henselae infection.
  Importantly, PCR analysis for Bartonella can be performed on material that was obtained recently and preserved by freezing.
  It is sensible to freeze extra material obtained by needle aspiration so PCR studies can be performed if bacterial studies are unexpectedly negative.

• Endemic (African): Occurs commonly in jaw.
• Non-endemic (Sporadic): Occurs commonly in abdomen
• Aggressive lymphoma: In HIV patients.

• It is commonly seen in children during the age of 6–9 years.
• Males are commonly affcted as compared to females.
• Male to female ration is 2:1.
• Lesion is found most commonly in maxilla and spreads towards flor of the orbit.
• In African form jaw is more involved while in American form abdominal involvement is common.
• Lesion has very fast growth and it doubles in size within a day.
• Patient complaints swelling of jaw, abdomen and paraplegia.
• Peripheral lymphadenopathy is commonly seen.
• Renal involvement is present which can be bilateral.
• In females, ovaries are also affcted.

• Tumor is rapidly growing and involves maxillary, ethmoidal and sphenoidal sinus along with orbit.
• Presence of loosening and mobility of permanent teeth.
• Presence ofparesthesia ofinferior alveolar canals and other sensory facial nerves.
• Gingiva adjacent to affcted teeth become swollen, ulcer ated and necrotic.
• There can be presence of large amount of mass in the mouth on the surface of which present the rootless developing permanent teeth.

• Radiograph: It shows moth-eaten appearance with loss of lamina dura.
• Biopsy: Starry Sky appearance is characteristic for Burkitts lymphoma.
• USG: This done for abdomen so that kidneys should be evaluated.
• Blood urea and serum creatinine estimation is done.

• Radiotherapy.
• Chemotherapy, i.e. cyclophosphamide, methotrexate,orthomelphalan.
• Surgery is usually not indicated unless it is localized or in case of involvement of ovaries.

• The tumor is seen in young adults, i.e. during 20 to 30 years or in elderly people during 5th decade of life.
• Onset of the tumor is insidious with enlargement of one group of superfiial nodes.
• Associated lymph nodes are painless. There is presence of generalized weakness, cough, dyspnea and anorexia.
• Lymph nodes are discrete and rubbery in consistency with overlying skin is purely mobile.
• Pel-Ebstein fever is present, i.e. presence ofcyclic fever with generalized severe pruritus which is of unknown etiology.
• In oral cavity, the lesion appears as an ulcer or swelling.
• It can also be present as intrabony lesion which appears as hard swelling.

• Non-specifi anemia of chronic disease is common
• Lymphopenia is present.
• ESR is elevated.

• Chest X-ray to look for mediastinal lymph nodes and pleural effusion
• CT is valuable in detecting intrathoracic and abdominal lymphadenopathy.

• Mainly radiotherapy, i.e. external high cobalt radiotherapy
• Above the diaphragm: Y fild therapy, covering cervical,axillary, mediastinal lymph nodes.
• Below the diaphragm: Mantle or inverted Y fild therapy covering para-aortic and iliac nodes.
• Chemotherapy is also given.

• In this, mainly chemotherapy is given.
  Regimens used are:

• Mechlorethamine: 6 mg/sqm on 1st and 8th day.
• Oncovine: 1.4 mg/sqm on 1st and 10th day.
• Procarbazine: 100 mg orally daily for 10 days.
• Prednisolone: 45 mg orally daily for 10 days.
• MOPP combination is given in 6 courses with no drugs given from 15th to 28th day.

• Adriamycin: 30 mg/sqm
• Bleomycin: 10 mg/sqm
• Vinblastine: 6 mg/sqm
• Dacarbazine: 350 mg/sqm

• Precursor B cell neoplasm: ALL, LBL.
• Precursor B cell neoplasm: It includes all B-cell-related non-Hodgkin’s lymphomas.

• Precursor B-cell neoplasm: ALL, LBL T cell related.
• Precursor T-cell and NK cell neoplasm: It includes all T cell related non-hodgkin’s lymphomas.

• Predominant Hodgkin’s lymphoma: Nodular lymphocyte type.
• Classical Hodgkin’s lymphoma:

• Nodular sclerosis
• Lymphocyte rich
• Mixed cellularity
• Lymphocyte depletion.

• Genetic predisposition
• Sjogren’s syndrome
• HIV infection
• Virus etiology, i.e. Epstein-Barr virus infection
• Occupational causes: Hair dye workers, herbicide exposure
• Ionising radiation
• Celiac sprue—Intestinal T-cell lymphoma
• Bloom’s syndrome.

• Hodgkin’s lymphoma
• Non-Hodgkin’s lymphoma

• Acute lymphadenitis
• Chronic non-specifi lymphadenitis
• Tuberculous lymphadenitis
• Infectious mononucleosis
• Toxoplasmosis
• Cat scratch fever.

• Metastatic lymph node enlargement
• Lymphomas, i.e Hodgkin’s lymphoma, Non-Hodgkin’s lymphoma, Burkitts lymphoma
• Chronic lymphatic leukemia.

• Autoimmune diseases, i.e. systemic lupus erythematosus,rheumatoid arthritis.
• HIV infection, Immunosuppression.

• It is a bacterial infection leading to acute inflmmation and suppuration of lymph nodes caused by group A streptococci or staphylococci.
• There is presence of tender, enlarged, fim or soft palpable neck lymph nodes.

• Infections such as chronic tonsillitis, recurrent dental
• infection can lead to chronic non-specifi lymphadenitis.
• There is presence of fim, non-tender, multiple, bilateral lymph node enlargement in neck.
• Tuberculous lymphadenitis
• It is caused by mycobacterium tuberculosis infection.
• Lymph nodes are mattd, enlarged with cold abscess or sinus formation.

• Caused by Epstein-barr virus.
• There is presence of generalized lymphadenopathy.
• Monospot test is positive.

• Caused by Toxoplasma gondii, protozoa through meat.
• Cervical lymphadenopathy is most common.
• Diagnosed by Sabin Feldman dye test.

• Caused by Bartonella henselae.
• Lymphadenopathy is present.
• Diagnosed by lymph node biopsy with Warthin-Starry staining.

• In Hodgkin’s lymphoma, there is painless progressive enlargement of lymph nodes.
  Lymph nodes are smooth,firm, non-tender. In this cervical lymph nodes, i.e. lower deep cervical group in posterior triangle are commonly enlarged.
  In this type, peripheral lymph node involvement is not common.
• In non-Hodgkin’s lymphoma any group of lymph node is involved. In this type, peripheral lymph node involvement is common.

• Each antitubercular drug has standard abbreviation, i.e.
• Isoniazid (H)
• Rifampicin (R)
• Pyrazinamide (Z)
• Ethambutol (E)
• Streptomycin (S).
• Numerical before a phase is the duration of that phase in months.
• Numerical in subscript is the number of doses of that drug per week. If there is no subscript numerical, then the drug is given daily.