From the Guidelines
Lymphadenopathy is a condition that requires immediate medical evaluation if the lymph nodes remain enlarged for more than two weeks without obvious cause, are progressively growing, or are accompanied by concerning symptoms, as it may be a sign of a serious underlying condition such as lymphoma or other malignancies. Lymphadenopathy refers to enlarged or swollen lymph nodes, which are small bean-shaped structures that filter lymphatic fluid and help fight infections. This condition is typically a sign that your immune system is responding to an infection or illness rather than a disease itself. Common causes include viral infections (like common cold, flu, or mononucleosis), bacterial infections (such as strep throat), immune disorders, and rarely, cancer.
Causes and Diagnosis
The diagnosis of lymphadenopathy involves a thorough medical history, physical examination, and laboratory tests to determine the underlying cause. According to 1, lymph node involvement generally has a self-limited disease, and does not require treatment. However, the finding of enlarged hilar and mediastinal lymph nodes during radiographic testing is often alarming to healthcare providers and patients alike, primarily out of concern for an alternative diagnosis, such as occult malignancy or latent infection.
Treatment and Management
Treatment focuses on addressing the underlying cause—antibiotics for bacterial infections, supportive care for viral illnesses, or specific treatments for other conditions. Most cases of lymphadenopathy resolve once the underlying infection clears. However, if lymph nodes remain enlarged for more than two weeks without obvious cause, are progressively growing, or are accompanied by concerning symptoms, medical evaluation is necessary to rule out serious conditions like lymphoma or other malignancies. As stated in 1, a definitive ALPS diagnosis requires a patient to meet both required criteria and one of the primary accessory criteria, and a probable ALPS diagnosis can be entertained by the presence of the required criteria and any one of the secondary accessory criteria.
Key Considerations
It is essential to distinguish between different causes of lymphadenopathy, such as tuberculous and non-tuberculous mycobacterial infections, as treatment and management differ significantly. According to 1, distinguishing tuberculous from NTM lymphadenitis is critical, because the former not only requires drug therapy but public health tracking as well. In asymptomatic bilateral hilar lymphadenopathy confirmed to have sarcoidosis, the committee suggests NOT sampling lymph nodes (conditional recommendation, very low certainty), as stated in 1.
Clinical Approach
A thorough clinical approach is necessary to evaluate lymphadenopathy, including a detailed medical history, physical examination, and laboratory tests. The presence of lymphadenopathy and/or splenomegaly, and elevated TCR -DNT cells, are required criteria for the diagnosis of ALPS, as stated in 1. The lymphadenopathy in ALPS typically fluctuates and involves the cervical, axillary, and inguinal chains, although mesenteric, retroperitoneal, pelvic, and mediastinal lymph node expansions are also often noted by imaging studies.
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From the Research
Definition and Causes of Lymphadenopathy
- Lymphadenopathy refers to the enlargement of lymph nodes, which can be caused by various factors, including malignancy, infection, autoimmune disorders, medications, and iatrogenic causes 2.
- The etiologies of lymphadenopathy can be classified into localized or generalized, with generalized lymphadenopathy often indicating underlying systemic disease 2, 3.
Diagnosis and Evaluation
- The history and physical examination alone usually identify the cause of lymphadenopathy, but when the cause is unknown, further evaluation is necessary 2.
- The workup may include blood tests, imaging, and biopsy, depending on clinical presentation, location of the lymphadenopathy, and underlying risk factors 2, 3.
- Biopsy options include fine-needle aspiration, core needle biopsy, or open excisional biopsy, with the aim of performing a histological analysis 3.
- In cases of malignant lymphoma, staging examinations should be conducted to assess the prognosis and formulate a treatment plan 3.
Risk Factors and Management
- Risk factors for malignancy include age older than 40 years, male sex, white race, supraclavicular location of the nodes, and presence of systemic symptoms such as fever, night sweats, and unexplained weight loss 2.
- Antibiotics may be used to treat acute unilateral cervical lymphadenitis, especially in children with systemic symptoms, while corticosteroids have limited usefulness in the management of unexplained lymphadenopathy 2.
- Antimicrobial prophylaxis is not recommended for patients with lymphoma, as it has no effect on the total incidence of infection episode and febrile neutropenia 4.
Clinical Approach
- A thorough clinical history, physical examination, laboratory studies, and imaging can help narrow a broad differential diagnosis and identify when enlarged lymph nodes may be associated with pathology 5.
- The goal of evaluation is to develop differential diagnoses associated with lymphadenopathy and apply a systematic approach for diagnostics and appropriate management, with a focus on findings concerning for malignancy and the initial evaluation 5.