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Linfoadenopatie
To be opposed to regional lymphopathies, in which single regional lymph node
chains are involved. Here the process is systemic, that is, it affects the whole
organism and the lymphonode stations are appreciated everywhere. The causes of
generalized lymphadenopathy are numerous and we give a summary of them below.
• Infections: viral syndromes can cause a generalized enlargement of the lymph
nodes, which can be painful; they are often associated with fever, rash,
headache, pharyngitis and myalgias. Infectious mononucleosis and cytomegalovirus
infection are clinically overlapping and are both characterized by generalized
lymphadenopathy. The finding of a large number of lymphocytes on a peripheral
blood smear should recommend diagnostic investigations such as the Paul Bunnel
reaction and the detection of anti-cytomegalovirus antibodies.
•Viral hepatitis can also cause enlarged lymph nodes. Findings such as jaundice,
liver disorder, and abnormal liver function test results (including an increase
in SGOT) facilitate the diagnosis of viral hepatitis, as well as the probable
etiology, especially if a history of patient exposure has been highlighted.
•A large number of bacteria can cause generalized adenopathy. Onset symptoms,
clinical history and physical examination may provide useful data to classify
the disease as chronic (leprosy, tuberculosis, syphilis) or acute (typhoid,
paratyphoid, leptospirosis, bacterial endocarditis, tularemia).
•Since disseminated fungal infections such as coccidioidomycosis, histoplasmosis,
blastomycosis and sporotrichosis may cause generalized adenopathy, attention
should be paid to a medical history that highlights a geographical or
occupational exposure or a recent unexplained feverish episode. In these cases
it may be necessary to perform a chest x-ray to search for infiltrates or
adenopathies, an X-ray of the abdomen to search for splenic calcifications,
serum antimycetes antibody research, a bone marrow or liver biopsy with special
stains and a fungi culture.
• Among the protozoan infestations, toxoplasmosis
should be considered a possible cause of adenopathy. In its acquired form,
toxoplasmosis can simulate infectious mononucleosis: however, the differential
diagnosis is based on the positivity of the reaction of Sabin and Feldman (dye
test) and on the negativity of the tests for infectious mononucleosis. Although
rare, Whipple's disease (intestinal lipodystrophy) is a possible diagnosis in
patients with intestinal malabsorption, arthritis and lymphadenopathy.
Frequently the biopsy of a peripheral lymph node allows to make the diagnosis;
however, in some patients a biopsy of the small intestine or even a laparotomy
may be necessary
• Inflammatory reactions. Lymphadenopathy may be a manifestation of connective tissue, such as rheumatoid arthritis and systemic lupus erythematosus.
For this purpose it is important to collect anamnestic data on the presence of
joint pain, fever, rashes and signs of peripheral ischemia. The examination of
the objective examination of joint abnormalities, facial skin, hair and
fingertips and the presence of an increase in erythrocyte sedimentation rate (ESR)
and a positive rheumatoid factor or antinuclear antibodies can confirm the
diagnosis of vasculitis . Generalized lymph node reactions are observed during
eczema, rash and fungoid mycosis, a typical T-cell cutaneous lymphoma. Finally,
in patients with uveitis, swelling of the salivary glands, erythema nodosus,
pulmonary abnormalities and bilateral hilar adenopathy, with or without
parenchymal infiltrates, the diagnosis of sarcoidosis should be suspected. While
a bilateral hilar adenopathy is suggestive of sarcoidosis, a swelling of the
mediastinal lymph nodes, in the absence of hilar alterations, suggests the
diagnosis of lymphoma.
• Hypersensitivity. Sometimes exposure to drugs can cause a generalized
enlargement of the lymph nodes, both in the context of a serum sickness and an
associated allergic reaction. For example, diphenylhydantoin can cause a "pseudolinfoma"
which, due to its clinical and histological characteristics, can hardly be
distinguished from malignant lymphoma. In this situation the suspension of the
drug, if possible, or its substitution with another anticomizial drug can solve
the diagnostic dilemma, favoring the return to normal of the enlarged lymph
nodes.
• Metabolic diseases. Generalized lymphadenopathy may occur in patients with
thyrotoxicosis. If objective data are found to support this diagnosis, it may be
necessary to perform thyroid function studies. Gaucher disease, Niemann-Pick
sphingomyelinosis and other lipid tesaurismosis diseases are sometimes
associated with generalized lymphadenopathy and can be diagnosed based on the
characteristic biopsy findings of the affected tissues.
• Malignant neoplasms. If none of the causes listed above can explain generalized lymphadenopathy, it
is important to exclude the possibility of myelitis or lymphoproliferative
disorders.
• Chronic myeloid leukemia is sometimes accompanied by generalized
lymph node enlargement and can generally be ruled out if the blood count and
peripheral blood smear are normal. On the other hand, acute and chronic
lymphatic leukemia are more often accompanied by lymphadenopathy. Also in this
case usually the blood count and the normal blood smear exclude these
pathologies; however, it is not possible to exclude other lymphoproliferative
disorders, such as Hodgkin's lymphomas or non-Hodgkin's lymphomas. In these
cases the bone marrow biopsy can show the presence of a lymphomatous
infiltration, even if to make a histological diagnosis it is necessary to
proceed to the biopsy of a suspicious peripheral lymph node. The prognosis and
considerations for possible chemotherapy should, at least in part, be based on
an accurate interpretation of the histology of the lymph node. For example, in
the case of non-Hodgkin's lymphoma, the histologic nodular type has a more
favorable prognosis than the diffuse type. If possible, a different lymph node
site should be chosen for the biopsy, since inguinal lymph nodes are often
altered by distal chronic infections and may make the histological
interpretation of the morbid processes occurring more difficult. Since sometimes
axillary lymph node biopsy is complicated by scarring difficulties, it should,
if possible, also be avoided. Regional adenopathy often leads the doctor to
discover a primary lesion or an easily identifiable lymph node syndrome.
A
peripheral blood sample may show a leukocytosis with an increase in
polymorphonucleates or reactive lymphocytes, thus facilitating confirmation of
the presence of an infection of bacterial or viral origin. Generally the germs
responsible for acute and self-limiting pathologies can be readily identified,
cultivated and properly treated without performing unnecessary biopsies.
Similarly, in generalized adenopathy, anamnesis, objective examination and
results of blood smear examination, they guide the execution of the first
investigations and often provide a diagnosis of presumption, as occurs in
infectious mononucleosis. Generally, in regional or generalized adenopathy, when
adenopathy persists and it is not possible to make any diagnosis, it is
necessary to perform a biopsy of the lymph node. When doubts exist about the
significance of lymph node enlargement, close observation over a period of four
to six weeks may help to ascertain whether the lymph node is swelling or
shrinking. If the enlargement does not resolve during this period of time, a
biopsy should be performed immediately. In cases where a specific infectious
etiology can not be highlighted, the practice of prescribing antibiotics to
patients with undiagnosed lin-foadenopathy should be discouraged.
Hematology