LIMFADENITIS AKUT DAN KRONIS

RUDY AFRIANTSUB-DIVISI HEMATOLOGI & ONKOLOGI MEDIK

BAGIAN ILMU PENYAKIT DALAM FKUA/RSUP M. DJAMIL PADANG

2015

Objectives• Etiologies of infectious lymphadenitis

• Clinical presentation

• Differential diagnosis

DD• M• I• A• M• I

Approach to lymphadenitis

History• Fever, malaise, anorexia, myalgias• Pain or tenderness of node• Sore Throat / URI / Toothache / Ear pain• Insect Bites • Exposure to animals• History of travel or exposure to TB• Medications

Physical Exam• General

– Febrile • Skin

– Cellulitis, impetigo, rash• ENT

– Otitis, pharyngitis, teeth, and nasal cavity• Neck

– Size– Unilateral vs Bilateral– Tender vs Nontender– Mobile vs Fixed– Hard vs Soft

• Lungs– Consolidations suggesting TB

• Abdomen– Hepatosplenomegaly

Laboratory Workup• CBC • Tuberculin test• Culture

Imaging Workup• CXR if malignancy susp. – To look for mediastinal

lymphadenopathy– Tuberculosis

• Ultrasound– Abscess?

• Sometimes CT/MRI– To evaluate for abscess

• EKG/ECHO– If suspect Kawasaki Disease

• Biopsy– FNA or Excisional

Suppurative Bacterial Lymphadenitis

• Staphylococcus aureus and Group A Streptococcus

• Anaerobes• Usually acute onset, fever• Management: antibiotics • If not resolving or getting worse

– Ultrasound and/or CT with contrast to evaluate for phlegmon/abscess/infiltrate

• FNA vs Surgical Excision if abscess is identified

Suppurative Lymphadenitis with Overlying cellulitis

Subacute Lymphadenitis• 2-6 weeks• Usually no improvement with antibiotics• DD:

• Atypical Mycobacteria• Cat Scratch disease• Toxoplasmosis• TB

Atypical Mycobacteria • Leading cause of sub-acute disease• Species involved:

• Mycobacterium avium-intrucellulare

• Mycobacterium scrofulaceum

• Develops over weeks to months• Lymph nodes may have violaceous skin over the node• No fever, no pain• Diagnosis: acid fast stain and culture • Treatment: surgical excision of involved lymph nodes, some

offer antibiotics

Cat Scratch Disease • Exposure to cat bite or scratch• Can take up to 2 weeks to develop• Tender. Fever & malaise are mild and

present in <50% of patients

• Diagnosis: serology or PCR• Treatment: none / antibiotics• Antibiotics always given to

immunocompromised patients to prevent disseminated disease

Toxoplasmosis -Toxoplasma gondii

• Mechanism– Consumption of undercooked meat– Ingestion of oocytes from cat feces

• Symptoms– Malaise, fever, sore throat, myalgias– 90% have cervical lymphadenitis

• Diagnosis: serology• Treatment: none. In pregnancy, congenital,

immunocompromised, retinitis: pyrimethamine sulfadiazine

Kawasaki Disease• Diagnosis: Fever>5 days :

– Unilateral Cervical lymphadenopathy – Edema of palms – Nonpurulent Conjunctivitis– Strawberry Tongue– Rash– Toxin of S, aureous implicated as a possible

etiology

– Common under 4 years

• Complications – Coronary artery aneurysms

• Treatment – IVIG and Aspirin

Chronic form of lymphadenitis : Mycobacterium tuberculosis Atypical mycobacterium Cat-scratch disease Toxoplasmosis

Mycobacterium species

• The most common cause of chronic unilateral , suppurative cervical lymphadenitis

• Positive tuberculin test will differentiated M. tuberculosis from atypical form .

• Minimally tender , spontaneous rupture • Atypical form is rarely associated with pulmonary

disease

Treatment

• M. tuberculosis :six month rifampin, isoniazide ,pyrazinamide

Atypical mycobacterium : Surgical excision

Summary• History and Physical exam• Further workup with serology, ultrasound, imaging, • Biopsy with resistant and chronic cases

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