A 57 year old woman comes to her family physician with the complaints of fever and lymphadenopathy in her neck.
How will you approach this case?
Clinical Approach:
There are a wide variety of causes of lymphadenopthy. Knowing theses causes helps in making a structured diagnosis. Majority of the causes for enlarged or swollen lymph nodes are benign and secondary to self limiting infectious causes. The probability for malignancy increases with age and should always be ruled out an any patient with lymphadenopathy.
Causes Of Lymphadenopathy: The important causes for lymphadenopathy include:
1. Infectious causes:
- Viruses: EBV, CMV, parvoviruses, HIV, hepatitis B, rubella.
- Bacteria: Staph aurypanosomieus, Strep. pyogenes, Tuberculosis
- Parasites: Toxoplasma species, Trypanosomiasis, Leshmaniasis
- Fungi: Coccidiodomycosis
2. Non- Infectious Causes:
- Malignancy: Metastatic disease, lymphoma, CLL
- Collagen Vascular disorders: SLE, reumatic arthritis.
- Miscellaneous: Sarcoidosis, Kwasaki's disease, amyloidosis
History Of The Presenting Problem:
1. What and How? A detailed description is required about:
- How long has the patient been unwell
- When did the patient first notice the enlarged lymph nodes.
- Has the patient noticed enlarged lymph nodes else where
- Has the patient measured the body temperature.
2. Are there any systemic features like:
- weight loss
- night sweats
- Rash on the body.
3. Travel History : is important and the time spent during the travel in the tropics helps in the diagnosis.
4. Sexual History: to rule out any sexually transmitted diseases.
5. Relevant Past History: like any previous history of malignancy, TB, STDs or connective tissue disorders.
Examination: Of the patient with lymphyadenopathy should include:
- General impression : does the patient looks well or unwell.
- Systemic examination of all lymph nodes.
- Look for hepatosplenomegaly
- Is there a local abnormality, especially with regional lymphadenopathy.
- Examination of breasts.
- A pale, thin aged patient with non tender lymphadenopathy has malignancy until proven otherwise.
- A flush and toxic looking patient with a swollen toe , lymphangitisand tender inguinal lymphadenopathy most probably has group A streptococcal or Staph aureus infection.
Investigations: includes:
- Complete blood count with a peripheral blood film ( atypical lymphocytes are commonly seen in EBV and CMV infections)
- Serum electrolytes
- Renal function tests
- Liver function tests
- Inflammatory markers like ESR and C reactive protein.
- Chest radiograph ( look for hilar involvement and check the lung fields)
- Fine needle aspiration / lymph nope biopsy ( histology will in most cases confirm the diagnosis)
Management: depends upon the cause.
1. Viral infections are mostly self limiting.
2. Malignancy cases should be refered to oncologists.
3. Mycobacterial infections need proper anti tuberculosis therapy.
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