Lymphadenopathy in head and neck region

Associate professor Elitsa Deliverska, PhD, Department of Dental, Oral and Maxillofacial

surgery, Faculty of Dental medicine, Medical University- Sofia

Introduction Description of lymph nodes Function of lymph nodes Distribution of lymph nodes Lymphadenopathy Causes of lymphadenopathy Pathogenesis of lymphadenopathy Clinical evaluation of lymphadenopathy Treatment

- Early recognition of disease almost always improves prognosis for recovery. - Lymphadenopathy is an early indicator of some diseases; therefore, physical

examination of lymph nodes of head and neck is of great importance.

- And one important responsibility of dental professional is to detect and record abnormal lymph nodes

Lymphatic system can be defined as closed system of channels through which the fluid is

drained from interstitial spaces into the blood venous system via thoracic & right lymphatic

duct.

Lymphoid Organs - Spleen - Thymus - Tonsils Lymph nodes Lymphoid Tissue Lymphatic Cells Lymph Lymph Capillaries Lymphatic Trunks Lymphatic Ducts

- Lymph nodes are 'bean' shaped organs found in clusters along the distribution of lymph channels of the body.

- Every tissue supplied by blood vessels is supplied by lymphatic's except placenta and brain.

- There are over 800 lymph nodes in the body and around 300 are located in the head and neck

- Lymph nodes usually occur in groups and are strategically arranged at various sites in the body.

The superficial nodes are located in the subcutaneous connective tissue, and deeper

nodes lie beneath the fascia & muscles and within various body cavities.

They are numerous and tiny, but some may have size as large as 0.5 to 1 cm in diameter.

The superficial nodes are the gateways for assessing the health of the entire lymphatic system

Lymph node structure

An oval-shaped organ of the immune system Distributed widely throughout the body. Linked by lymphatic vessels. Lymph nodes act as filters for foreign particles. Become enlarged in various conditions.

Lymph node function:

They are centers of lymphocyte production. Both B-lymphocytes and T-lymphocytes are produced here by multiplication of pre-existing lymphocytes.

Filter the products from lymph such as bacteria and other particulate matter and to prevent their entry into systemic circulation.

The antibodies produced by the B-Lymphocytes are carried to the circulation and indirectly help in mounting an immune response.

Waldeyer's tonsillar ring, consisting of an unpaired pharyngeal tonsil in the roof of the

pharynx, paired palatine tonsils and lingual tonsils scattered in the root of the tongue.

Modified from Kahle et al. Color Atlas and Textbook of Human Anatomy.

Arch Otolaryngol Head Neck Surg. 1999;125:388-396

Level I The submental and submandibular nodes.

They lie above the hyoid bone, below the mylohoid muscle and

anterior to the back of the submandibular gland.

Level IA The submental nodes.

They lie between the medial margins of the anterior bellies of the

digastric muscles.

Level IB The submandibular nodes- anterior, medius and posterior group.

On each side, they lie lateral to the level IA nodes and anterior to

the back of each submandibular gland.

Level II The upper internal jugular nodes.

They extend from the skull base to the level of the bottom of the

body of hyoid bone.

They are posterior to the back of the submandibular gland and

anterior to the back of sternocleidomastoid muscle.

Level IIA A level II nodes that lies either anterior, medial, lateral or posterior

to the internal jugular vein. If posterior to the vein, the node is

inseparable from the vein.

Level IIB A level II nodes that lies posterior to the internal jugular vein and

has a flat plane separating it and the vein.

Level III The middle jugular nodes.

They extend from the level of the bottom of the body of the hyoid

bone to the level of the bottom of the cricoid arch.

They lie anterior to the back of sternocleidomastoid muscle.

Level IV The low jugular nodes.

They extend from the level of the bottom of the cricoid arch to the

level of the clavicle.

They lie anterior to a line connecting the back of the

sternocleidomastoid muscle and the posterolateral margin of the

anterior scalene muscle.

They are also lateral to the carotid arteries.

Level V The nodes in the posterior triangle.

They lie posterior to the back of the sternocleidomastoid muscle

from the skull base to the level of the bottom of the anterior

scalene muscle from the level of the bottom of the cricoid arch to

the level of the clavicle.

They also lie anterior to the anterior edge of the trapezius muscle.

Level VA Upper level V nodes extend from the skull base to the level of the

bottom of the cricoid arch.

Level VB Lower level V nodes extend from the level of the bottom of the

cricoid arch to the level of the clavicle.

Level VI The upper visceral nodes.

They lie between the carotid arteries from the level of the bottom

of the body of the hyoid bone to the level of the top of the

manubrium.

Level VII The superior mediastinal nodes.

They lie between the carotid arteries below the level of the top

of the manubrium and above the level of the innominate vein.

Supraclavicular nodes They lie at or caudal to the level of the clavicle and lateral to

the carotid artery on each side of the neck.

Retropharyngeal nodes Within 2 cm of the skull base, they lie medial to the internal

carotid arteries.

Arch Otolaryngol Head Neck Surg. 1999;125:388-396.

Submental lymph nodes

Draining area: lower lip, the chin, tip of the tongue and the anterior floor of the mouth

Efferent’s: - Submandibular nodes or jugulo- omohyoid group

Submandibular lymph nodes

Draining area: • Submental nodes • Mandibular frontal teeth • Vestibular gingiva • Posterior floor of the mouth • Tongue

Efferent’s: Drain into nodes of deep cervical chain Buccal lymph nodes

• Maxillary teeth • Cheek- mucosa and skin • Nose

Premasseterial /mandibular/

Draining área: cheek, vestibular mandible mucosa/gingiva

Parotid lymph nodes and Preauricular lymph nodes

Draining area:

• the eye lids • temple • prominence of cheeks and • the auricle Efferent’s:

• deep parotid nodes • Superficial cervical nodes

Retro auricular nodes

• Draining area: The Scalp • The Auricle

Efferent’s: Deep cervical nodes Occipital

Draining area: From scalp

Efferent’s: Drain to deep cervical nodes

Superficial cervical LN

• Draining area: floor of external acoustic meatus • Lobule of the ear • angle of the jaw

Efferent’s: Lower deep cervical LN

Lower deep cervical lymph nodes

- Jugulo-Digastric- draining area- Palatal tonsils, Posterior 1/3rd of tongue, subnadibular LN; efferents: Lower group of Deep Cervical nodes

- Jugulo- omohyoid- draining area - Directly from the tongue and indirectly from submental, sub mandibular, upper deep Cervical nodes.

Tongue

Tip Submental LN

Anterior 2/3rds Submandibular & deep cervical LN

Posterior 1/3rd Jugulodigastric lymph nodes LN

Lymphadenopathy- Definition: Lymph nodes that are abnormal in either size or

consistency.

- Localized- only one area is affected - Generalized- involvement of two or more noncontiguous lymph node areas.

Generalized lymphadenopathy is frequently associated with nonmalignant

disorders

Causes:

• Malignancies, • Infection s- bacterial, viral, fungal, parasitosis • Autoimmune disorders, • Miscellaneous and unusual conditions, and • Iatrogenic causes.

Infections

Bacterial

Group A streptococcus Mycobacteria: typical and atypical Anaerobic, aerobic bacteria Diphtheria Brucellosis Tularemia Actinomycetes

Viral

Epstein-Barr virus Herpes simplex Measles Mumps Coxsackie Adenovirus HIV Rubella Cytomegalovirus

Fungal, parasitic

Aspergillosis Candida Cryptococcus Histoplasmosis Coccidioidomycosis Sporotrichosis Blastomycosis Toxoplasmosis- is a protozoic disease- Toxoplasma gondii

Lymph node enlargement is a common feature in a variety of diseases and may serve as a

focal point for subsequent clinical investigation of diseases of the reticuloendothelial system

or regional infection. The majority of cases represent a benign response to localized or

systemic infection.

Lymphadenitis may affect a single node or a group of nodes (regional adenopathy) and

may be unilateral or bilateral. The onset and course of lymphadenitis may be acute, subacute,

or chronic.

Malignant

- Oral or in draining areas(metastatic) - Lymphoid- Hodgkin, non-Hodgkin Lymphomas, Leukaemia, Kaposi’s sarcoma

- Iatrogenic- serum sickness, medication/drugs Allopurinol, Atenolol, Captopril, Carbamazepine, Gold, Penicillin’s, Phenytoin, Primidone, Pyrimethamine, Quinidine/

Miscellaneous

• Mucocutaneous lymph node syndrome- Kawazaki disease- medium sized blood vesssels become inflamed. Recurrent fever- 10 days, swelling of feet and hands,

coronary artery aneurysms, conjunctivitis of the eyes, mucous membrane of the

mouth become inflamed.

• Sarcoidosis, Histiocytosis X

• Castleman’s disease (giant lymph node hyperplasia)

Autoimmune

• Rheumatoid arthritis • Juvenile rheumatoid arthritis • Mixed connective tissue disease • Systemic lupus erythematosus • Dermatomyositis • Sjögren’s syndrome • Serum sickness

Mimicking Lymphadenopathy:

Branchial cleft cyst Cystic hygroma Thyroglossal duct cyst Epidermoid cyst Sternocleidomastoid tumor Tumour of accessory gland of buccal region Parotid tumour Haemodectoma Lipoma

Lipomas should not be confused with Madelung disease, also known as Launois Bensaude

disease, which occurs in middle aged. European men of Mediterranean descent with a history

of alcohol abuse. In these patients, fat accumulates in the cervical and upper dorsal regions,

abdomen and groin.

Buccal lymph node swelling – differential diagnosis of local lymphadenitis because of dental

infection and accessory gland tumour.

Herzenberg pseudoparotitis- lymphadenitis of intraparotid lymph nodes

Lymphadenopathy - pathophysiology Lymph node enlargement may occur via any of the following mechanisms:

◦ Nodal cells may replicate in response to antigenic stimulation or malignant transformation (e.g., lymphoma).

◦ Large number of reactive cells from outside node (e.g., neutrophils or metastatic cells) may enter node.

◦ Foreign material may be deposited into node by lipid-laden histiocytes (e.g., lipid storage diseases).

◦ Vascular engorgement and edema may occur secondary to local cytokine release.

◦ Suppuration secondary to tissue necrosis (e.g., Mycobacterium tuberculosis) The causes of lymphadenopathy is broad. A patient's medical history and review of systems

is important in narrowing the differential diagnosis. Upon examination, recognizing the

pattern of lymph drainage aids in seeking an infectious focus/odontogenic infection.

Lymphangitis

Lymphangitis is defined as an inflammation of the lymphatic channels that occurs as a result of infection at a site distal to the channel.

when pathogenic organisms enter the lymphatic channels, invading directly through an abrasion or wound or as a complication of infection, local inflammation and

subsequent infection ensue, manifesting as red streaks on the skin. The inflammation

or infection then extends proximally toward regional lymph nodes. Bacteria can grow

rapidly in the lymphatic system

LYMPHANGITIS-inflammation of peripheral lymphatics

• acute, chronic • appear as red streaks progressing towards regional LN most common Beta-hemolytic streptococci, Staphylococcus aureus

infections

Lymphadenitis – node it’s self is infected- the node is enlarged, red , warm, tender- no streaking enlarged and later abscess may occur

Acute- serous or purulent Reticular Truncular

Conditions that increase the risk of lymphangitis include:

diabetes immunodeficiency (loss of immune function) chronic steroid use varicella (chicken pox)

◦ Treatment -conservative Penicillin group - drug of choice

Complication- cellulites, bacteriemia, sepsis

In chronic lymphangitis -repeated attack of Acute Lymphangitis LYMPHADENITIS

Lymphoid tissue increases in amount as a result of antigenic stimulation Enlargement of lymph node most frequently results from proliferation of intrinsic

lymph node structures primarily in the germinal follicles and interfollicular areas.

Repeated challenges cause an overall increase in lymphoid tissue. In some cases, nodes become infected by filtered lymph from an infected area and

develop inflammatory changes similar to the primary involved tissue, In addition to

primary proliferative responses.

Lymph node enlargement also develops from invasion of node by extrinsic. Classification

Acute Chronic

Localized Generalized

Nonspecific Specific (Tuberculosis, syphilis, actinomycosis)

Single node or a group of nodes (regional adenopathy) and may be unilateral or

bilateral

Draining of an infection (eg, abscess) into local lymph nodes Acute non specific lymphadenitis

• All kinds of acute inflammation in oral and maxillofacial area can cause this(pericoronitis, periodontitis, periodontal pocket disease, osteomyelitis, stomatitis,

foliculitis, etc. )

• the stimuli could be: Microbial infection Their breakdown products

Foreign body etc. • The lymphoid follicles become enlarged due to mitosis • The sinuses are congested, dilated and edematous • In more severe cases necrosis may occur and abscess formation can occur.

Aspects of the physical examination are as follows:

Location - Depends on underlying etiology (see Table below) Number - Single, local groupings (regional), or generalized (ie, multiple regions) Size/shape - Normal lymph nodes range in size from a few millimeters to 2 cm in

diameter; enlarged nodes are greater than 2-3 cm with regular/irregular shapes

Consistency - Soft, firm, rubbery, hard, fluctuant, warm Tenderness - Suggestive of an infectious process but does not rule out malignant

causes

Acute- tumour, color, dolor, rubor, functio lease Progression of the infection

Serous

Purulent

Abscessus nodi lymphatici

Adenophlegmona

Abscessus-a localized collection of pus surrounded by inflamed tissue

Adenophlegmona- a purulent inflammation and infiltration of connective tissue lymph

node capsule is destroyed(ruptured).

When an area in maxillofacial region becomes infected, body's immune system tries to fight

the infection. White blood cells go to the infected area, collect within the damaged tissue, and

cause inflammation. During this process, pus forms. Pus is a mixture of living and dead white

blood cells, germs, and dead tissue.

Local Signs and Symptoms

Pain Swelling Surface erythema Pus formation Limitation of motion

Systemic Signs and Symptoms

Fever Malaise Toxic appearance Elevated white blood cell count, ESR, CRP

Management

Acute stage

Treatment of focus of infection Antibiotic therapy Surgical incision and drainage if needed

The antibiotic treatment involves contemporary broad-specter antibiotics of the penicillin or

cephalosporin range; in severe cases the culture and sensitivity testing are obligatory and

serves later as the guideline for the choice of the antibiotic.

Chronic lymphadenitis

The nodes become moderately enlarged, slightly tender and elastic with or without matting.

Lymphadenitis chronica gramulomatosa;

Lymphadenitis chr.purulenta cum fistula cutanea;

Lymphadenitis chr. exacerbata;

Lymphadenitis chr. fibrosa;

Management

Treatment of odontogenic focus of infection

Antibiotic therapy- at least 10 days

Surgical– if needed removal of the lymph node/curettage and excision of fistula

If no response- biopsy

Clinical evaluation of patient with lymphadenopathy

Medical History- Reveals the setting in which lymphadenopathy is occurring. General information, accompanying symptoms, personal and social history.

Physical Examination - Inspection - palpation

Laboratory Tests LN Biopsy

Are there unusual epidemiological clues???

Exposure to pets (cats) Travel to any endemic area Exposure to bird droppings Lacerations during gardening Exposure to TB(tuberculosis) h/o tobacco use, alcohol, smoking, i/v drug abbuse Sexual exposure

History of presenting complaints

- Duration - Which group LN was 1st affected? - Pain - Fever - Primary focus - Loss of appetite & wait - Weight loss - Increased night sweating - Sore throat - Cough - Pressure effects

Past history

- Basophiles, any upper respiratory tract infection, odontogenic infection, etc. - recent blood transfusion. - immune suppression. - Any viral infection - HISTORY OF MEDICATION: phenytoin, cyclosporin,allopurinol ,carbamazepine,

hydralazine

Family history- h/o any TB in family, any malignancy (lymphoma)

Examination of status generalis praesens include:

I. Malnutrition

II. Anemia III. Icterus IV. Lymphadenopathy V. Edema

Remember:

Normal lymph nodes are not palpable Examine the draining lymph nodes area of any lesion Examine the area drained by affected lymph nodes The physical examination should be regionally directed by knowledge of the

lymphatic drainage patterns and should include a complete lymphatic examination

looking for generalized lymphadenopathy.

The physical examination should be regionally directed by knowledge of the lymphatic

drainage patterns and should include a complete lymphatic examination looking for

generalized lymphadenopathy.

• Swellings at the known sites of lymph nodes should be considered to have arisen from them unless some outstanding clinical findings prove their origin to be otherwise.

• All the normal anatomic sites should be inspected for any obvious enlargements When lymphadenopathy is localized, the clinician should examine the region drained by the

nodes for evidence of infection (mucosa, skin, odontogenic etc. ), lesions or tumors.

Other nodal sites should also be carefully examined to exclude the possibility of

generalized lymphadenopathy.

Technique of palpation: use the pads of the index and middle finger to move the skin in circular motions over the underlying tissues in each area

The following points are to be fulfilled during palpation Confirm the inspection Temperature Tenderness Consistency Mobility Special signs Draining area Matted or not SSSSS (5S):

1- Site.

2- Shape.

3- Size.

4- Surface: Smooth, nodular, irregular.

5- Skin overlying the swelling (scars, colour…).

6- Other draining lymph nodes.

7- Number

8- Pressure effect

Consistency

- Enlarged lymph nodes should be palpated carefully with palmar aspect of 3 fingers. - While rolling the fingers over the lymph node, slight pressure has to be applied to

know the consistency of the node.

- Enlarged lymph nodes could be Soft (fluctuant)

Elastic, rubbery

Firm,

Stony hard

Variable

- The enlarged nodes should be carefully palpated to know if they are fixed to the skin, deep fascia, muscles etc.

- Any primary malignant growth or secondary carcinoma is often fixed to the surroundings.

- First the deep fascia and the underlying muscle, the surrounding structures and finally the skin is involved.

- Upper deep cervical lymph nodes when involved secondarily from any carcinoma of its drainage area may involve the hypoglossal nerve and cause hemiparesis of the

tongue which will be deviated towards the side of the lesion when asked to protrude

out.

- Cases are not uncommon when patient may complain of dyspnea and dysphagia due to pressure on trachea or esophagus by enlarged lymph nodes from Hodgkin’s

disease or secondary carcinoma

Sequence to palpate cervical lymph nodes

- Begin with the most superior nodes and work down to clavicle - Anterior to tragus of the ear for pre-auricular node - Then mastoid and base of the skull for posterior auricular and occipital nodes - Under the chin for submental nodes - Then proceed further to palpate submandibular & sublingual lymph node - Examination of deep cervical lymph nodes - To examine ask the patient to sit and

them turn the head to one side to relax sternocleidomastoid muscle, use thumb and

finger to palpate under the anterior and posterior border of relaxed muscle and repeat

on other side.

- Examination of the cervical nodes can be accomplished by instructing the patients to turn the neck away from the side to be examined.

- This position distends the Sternocleidomastoid muscle and facilitate easier examination of the lymph nodes of anterior and posterior chain.

- Finger tips of the hand are placed along the posterior border of muscle while the thumb provides counter pressure from the anterior aspect of the muscle

Paraclinical examination

Complete Blood Count- Useful for detecting some lymphoproliferative disorders, chronic lymphocytic leukaemia and atypical mononuclear cells associated with viral

syndromes, the presence of anaemia (or other cytopenia’s) suggest significant

underlying illness

Chest Radiography Serological investigation- for Epstein-Barr virus, Toxoplasma (IgM, IgG), Dengue

(IgM, IgG), Cytomegalovirus (IgM, IgG), HIV, etc

Investigations for underlying autoimmune conditions- - ANA - iAnti- dsDNA - Complement C3/C4 - Rheumatoid factor Biochemical tests: LDH, Liver function tests, Calcium and phosphate, Uric acid ESR, CRP Nodal Biopsy Fine Needle Biopsy Bone Marrow Aspiration C. T. Scan M.R.I

Lymphography PET scan

Unexplained lymphadenopathy without signs or symptoms of serious disease or malignancy

can be observed for one month, after which specific imaging or biopsy should be performed.

Fine-needle aspiration, excisional biopsy remains the initial diagnostic procedure of choice.

Modern cross-sectional imaging modalities such as ultrasound(US), computed tomography

(CT) and magnetic resonance (MR) imaging allow reliable detection of cervical lymph nodes,

but the differentiation between benign and malignant lymph nodes remains challenging.

Alternative imaging modalities such as single photon emission computed tomography

(SPECT) and positron emission tomography (PET) can help to differentiate between benign

and malignant lymph nodes.

Sentinel node biopsy has greater accuracy in determining lymph node status for cancer than

current commonly used imaging methods. The sentinel nodes are the first few lymph nodes

into which a tumor drain. CMAJ 2008;178(7):855-62

Role of the doctor of dental medicine

As public health dentists are the closest to the public – to the population, they should

understand the lymphatic system and their diseases so as to identify them while general

clinical examination in field studies and advice/perform necessary basic treatment and refer

them for specific treatment.

• Investigations should be guided by the clinical presentation. • Any lymph node enlargement in neck that persists for more than 2 weeks suggests

need for investigation or to detect the source of infection.

Lymphography- valuable tool for detection of lymphatic fistulas and lymphatic leakage

Ethidiol Lymphangioscintigraphy

Tc-99m albumin –intradermally, and after 1 minute

and again after 10–30 minutes,

High-resolution scintiscan camera • Ultrasonography • Computed Tomography • PET scan • MRI (MR lymphography) • Fluorescein Micro lymphangiography (isothiocynate) Positron Emission Tomography-PET scan – it relies on the enhanced metabolic activity

of the tumour, of which increased glycolysis is the biochemical hallmark. FDG (2-F-

fluoro-2-deoxy-D-glucose), a radiolabeled glucose analog is preferentially taken up

within tumour cells that exhibit increased glycolysis; they can be detected from the

increased signaling in that tissue.

• Drawbacks of the method include the inability to differentiate between cancerous and reactive inflammatory lymph nodes and poor anatomic delineation of the primary

tumour and nodes in relation to surrounding structures, especially of vascular nature.

• Treatment is determined by the specific underlying etiology of lymphadenopathy • Most clinicians treat children with cervical lymphadenopathy conservatively • Antibiotics should be given only if a bacterial infection is suspected • If the clinical picture exists suggest malignancy, such as persistent fevers, weight loss,

or more impressive adenopathy with weight loss, biopsy should be pursued sooner

Surgical Care

Surgical care usually involves a biopsy.

If lymphadenitis is present, aspirate may be needed for culture, incision and drainage in acute and removal (curettage)of the affected node may be indicated in chronic

cases.

Drainage is required if an abscess formed

Indications of biopsy

1. Failure to reach diagnosis by noninvasive investigation 2. if there is persistent or unexplained fever, weight loss, night sweats, hard nodes, or

fixation of the nodes to surrounding tissues.

3. If there is supraclavicular LN 4. If there is continuous enlargement over 2 weeks 5. no decrease in size in 4–6 weeks 6. no regression to "normal" in 8–12 weeks 7. development of new signs and symptoms. 8. no respond to antibiotics

Important for diagnosis is:

Patient's age Localized or generalized lymphadenopathy Clinical characters of the nodes Duration of the swelling Associated signs or symptoms

Key features

Regional lymphadenopathy involves enlargement of a single node or multiple contiguous

nodal regions.

Cervical

1. Viral upper respiratory infection 2. Odontogenic infection 3. Infectious mononucleosis 4. Rubella 5. Cat scratch disease 6. Streptococcal pharyngitis 7. Acute bacterial lymphadenitis 8. Toxoplasmosis 9. Tuberculosis/atypical mycobacterial infection 10. Sarcoidosis 11. Acute leukemia 12. Lymphoma 13. Neuroblastoma 14. Rhabdomyosarcoma 15. Kawasaki disease

Submaxillary and submental

1. Oral and dental infections 2. Acute lymphadenitis

Occipital 1. Pediculosis capitis 2. Tinea capitis 3. Secondary to local skin infection 4. Rubella 5. Roseola

Preauricular 1. Local skin infection

2. Chronic ophthalmic infection 3. Cat scratch disease

Lymphadenopathy is defined as lymph nodes that are abnormal in size, consistency or

number. The extent of lymphadenopathy is defined as localized, regional or generalized.

Lymphadenopathy is commonly encountered by physicians in clinical practice and requires a

comprehensive evaluation. In patient’s evaluation the physician should pay close attention to

the size, location, consistency and number of enlarged lymph nodes, as well as to the patient's

age and any associated symptoms. Lymphadenopathy may be due to malignancy(metastatic

or lymphoreticular origin-Leucosis, lymphomas), infection, collagen vascular disease,

atypical lymphoproliferative disorders, granulomatous diseases and other miscellaneous

causes.

Lyme disease is caused by a spirochete, Borrelia burgdorferi, which is transmitted by

insects, particularly deer ticks.

Typical features of Lyme disease • A rash spreading outward from the insect bite • Enlarged regional lymph nodes • Fever and often other systemic symptoms • Arthritis (the main chronic effect) particularly of the knees, rarely of the

temporomandibular joints

• Neurological complications (in about 15% of patients) include facial palsy or other cranial nerve lesions

Infectious mononucleosis

IMN: Epstein Bar Virus - DNA virus

Petechial leasions on palate in a young children with cervical lymphadenopathy,flu- like symptoms- fever, sore throat and malaise, Palatal enanthem,

hepatosplenomegalia

All people give medication from penicillin group eventually develop a generalized, itchy

maculopapular rash- adverse reaction of penicillin; self-limiting infection in most of cases

Serologic test: IgG) and IgM tests. IgG, when positive, reflects a past infection, whereas

IgM reflects a current infection. Elevated hepatic transaminase levels is highly

suggestive of infectious mononucleosis, occurring in up to 50% of patients

Typical features of Kawasaki's disease

• Children under 5 years old affected

• Fever persisting for more than 5 days

• Generalized, often morbilliform rash

Palms and soles become red, swollen and indurated

• Erythematous stomatitis

Swelling and cracking of the lips and pharyngitis

• Unilateral mass of cervical lymph nodes

• Abdominal symptoms frequently

• Deterioration of mood ('extreme misery')

• Heart disease in approximately 20%

Cat-scratch disease (CSD) is a bacterial infection spread by cats- Bartonella henselae - The

disease spreads after Cat Scratch or bite hard enough to break the surface of the skin.;Or

when an infected cat licks a person’s open wound, About three to 14 days after the skin is

broken, a mild infection can occur at the site of the scratch or bite- a vesicle or an

erythematous papule. The infected area may appear swollen and red with round, raised

lesions. A person with CSD may also have a fever, headache, poor appetite, and fatigue.

Later, the person’s lymph nodes near the original scratch or bite can become swollen, tender,

or painful 1-3 weeks after inoculation- benign self-limiting lymphadenopathy.

PCR diagnostic

Antibiotic treatment for imunocompromised patient- one of the medications clould be used: Azithromycin, Doxycycline, Ciprofloxacin, Biseptol, Gentamycin

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Shafer's Textbook of Oral Pathology, 2012

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