Lymphadenopathy is defined as a lymph node that is greater than 1 cm in diameter. Most cases of lymphadenopathy are related to infections: these resolve independently or after antibiotic treatment.
Lymph node sites
| Lymph node site | Area drained |
|---|---|
| Cervical | Head and neck |
| Submental and submandibular | Buccal mucosa, cheek, and nose |
| Right supraclavicular | Thorax |
| Left supraclavicular | Abdomen |
| Axillary | Ipsilateral arm, breast, neck, and thorax |
| Inguinal | Ipsilateral leg, buttock, and lower half of abdominal wall |
Characteristics of lymph nodes on palpation
| Finding | Description |
|---|---|
| Firm, rubbery, or hard | This is concerning for malignancy. The texture is caused by infiltration of malignant cells. A hard lymph node feels like a stone – like the forehead (metastatic cancer); a firm or rubbery lymph node feels firmer than surrounding fat tissue – like the tip of the nose (lymphoma); a soft consistency is more likely due to infection or inflammation |
| Fluctuant | Feels like an abscess. May contain fluid and be compressible. Commonly associated with infections |
| Mobile | Can be freely moved within the surrounding tissue |
| Fixed | Stuck to the surrounding tissue and is immobile |
| Shotty | Many tiny, scattered lymph nodes in the same area. Occurs in cervical lymph nodes after viral infection in children |
| Matted | Lymph nodes that feel connected or form a continuous mass. Associated with malignancy or chronic inflammation, e.g., tuberculosis |
| Tender | Associated with inflammatory or infectious causes. It can also occur in malignancy due to necrosis or hemorrhage into the lymph node |
Causes of lymphadenopathy
| Cause | Description |
|---|---|
| Viral infection | The most common cause in children. URTI causes cervical lymphadenopathy. Should resolve in 4 – 7 days without antimicrobial treatment. Up to 18% of HIV-affected patients in Africa have lymphadenopathy on presentation |
| Bacterial infection | Reactive lymphadenopathy in lymph nodes that drain the area of infection. May result in abscess formation within the lymph node. Abscesses < 1.5 cm are treated with antibiotics, while those > 1.5 cm should be drained. |
| Tuberculosis lymphadenitis (scrofula) | The most common extrapulmonary manifestation of TB. Typically in the supraclavicular lymph nodes, but it can also affect other areas. Progresses to ‘cold abscesses’ and then to draining sinuses. Aspiration shows caseous or purulent material. Diagnosed by FNA with PCR, though Chest X-ray or PPD may be suggestive. |
| Atypical mycobacteria (MOTT) | A cause of lymphadenopathy in children, especially of the facial or cervical regions. Usually involves submental nodes. Similar to tuberculous lymphadenopathy. Treated with clarithromycin and rifampin for 6-9 months |
| Malignancy | 12% of biopsied lymph nodes are malignant. Lymphoma is the most likely cause (70%). Other rare causes are head and neck cancer, metastasis, and Kaposi’s sarcoma. |
- Patient History
- Location
- Duration
- Change in size
- Treatments performed and response
- Presence of B-symptoms
- Fever
- Night sweats
- Easy bruising
- Fatigue
- Weight loss
- Travel, animal, or insect exposure
- Medical history, including infectious diseases, e.g,. tuberculosis and HIV
- Physical examination
- Location:
- Examine all lymph node basins – submental, submandibular, parotid, anterior cervical, posterior cervical, supraclavicular, axillary, and inguinal regions
- Size
- Palpation and description of findings
- Other physical exam findings:
- Skin changes
- Bruising
- Rashes and other skin lesions
- Neck range of motion
- Hepatosplenomegaly
- Location:
- Investigations
- Complete blood count to identify infectious etiologies and hematologic malignancies
- Liver function tests, depending on the history
- HIV, EBV, CMV, Hepatitis ,B and Herpes Serology
- Chest radiograph to identify mediastinal lymphadenopathy, which is associated with lymphoma, and lung pathology consistent with tuberculosis
- Ultrasound for information about the size, shape, and number of lymph nodes and their morphologies and vascular patterns
- Excisional biopsy is the gold standard test for tissue diagnosis since it allows the tissue architecture to be visualized when the whole node is removed
- Fine needle aspirate (FNA) is not recommended for paediatric lymphadenopathy due to false-negative results
- Indications for biopsy
- Suspicion of malignancy
- Persistent lymphadenopathy (after 4 – 6 weeks)
- Size > 2 cm
- Increase in size over 2 – 3 weeks
- Multiple nodes with concerning features on ultrasound or CT