TOC |
D-Dx
Lymphadenitis
Outlines in Clinical Medicine
on Physicians' Online
2001
A. Acute
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Staphylococcus - most common cause
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Streptococcus - often with lymphangitis
B. Chronic
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Mycobacterium - particularly atypicals (M. marinarum)
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Tularemia - Francilla tullarensis
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Cat Scratch Disease - Bartonella hensii
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Plague - Yersinia pestis
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Rat Bite Fever
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Rickettsia
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Fungi - especially Sporthrix schenckii
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Protozoa and Helminths
C. Buboes
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Tender, enlarged lymph nodes
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Lymphogranuloma Venerium - Chlamydia trachomatis
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Chancroid - Haemophils ducreyi
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Herpes Simplex Virus (HSV)
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Syphilis - Treponema pallidum
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Donavanosis - Calymmatobacterium granulomatis
A. Definitions
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Lymphangitis = Inflamed lymphatic channels
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Lymphadenitis = Inflamed lymph nodes
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Acute Lymphangitis
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Linear erythematous streaks extending from primary lesion
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Usually caused by streptococcal infections (usually Group A streptococcus)
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Staphylococcus aureus causes lymphadenitis (with less streaking from lesion)
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Nodular Lymphangitis = Nodular subcutaneous swellings along involved lymphatic
glands
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Swelling, erythema, ± fever
B. Etiology of Chronic Lymphangitis / Lymphadenitis
Arthropod + animal vectors account for lymphadenitis in ~60% of patients
Sporothrix schenckii
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Often associated with gardening, rose thorn skin prick
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Fungal infection treated with itraconazole
Mycobacteria - "Scrofula"
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Mycobacterium marinum - lymphangitis
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Mycobacterium scrofulaceum and other atypicals (lymphadenitis)
Leishmania braziliensis
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Mainly only in Texas in the USA; South America and Central America, other
places
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Usually plaques, papules, and nodules, restricted to skin ("oriental sore")
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Visceral leishmaniasis (kala-azar) - fever, organomegaly, cytopenias, highly
lethal
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Liposomal amphotericin B is effective in skin lesions, some visceral lesions
Francisella tularensis
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Transmitted by ticks, mosquitos, or through rabbit or cat bites or handling
carcasses
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Small, non-motile, facultative, intracellular, gram negative coccobaccilus
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Usually in California and south central USA; reported in all states exept
Hawaii
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Ulceroglandular or typhoidal forms
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Ulceroglandular form includes painful, erythematous ulcer (60%) at site of
initial lesion
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Ulcer often includes frank pus
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Other symptoms include lymphadenitis, fever, chills, headache, cough, myalgia
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May also present as an typhoidal form in ~25% of cases, as atypical pneumonia
[5]
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Streptomycin 15mg/kg bid for 10-14 days is first line
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Gentamicin 1.5-2.5mg/kg bid for 10-14 days also effective
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Tetracycline and doxycycline are alternatives but have high relapse rates
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Tularemia vaccine is now in clinical trials
Nocardia brasiliensis - often with frank pus
Others
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Plague - Yersinia pestis (see below)
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L. venereum - chlamydia
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Cat scratch disease
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Anthrax
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Rat bite fever
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Rickettsial infection: such as scrub typhus, Ehrlichosis
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Kawasaki Disease
C. Buboes
Means tender, enlarged lymph nodes (lymphadenitis)
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Syphilis - secondary infection
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Primary genital herpes simplex infection
Chancroid
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Haemophilus ducreyi
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Gram negative coccobacillus, difficult to culture
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Uncommon in USA
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Initially, small papule or pustule, red lesions on genitalia, ulcerates then
very painful
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Painful adenopathy, inguinal region, ~50% of cases
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Treatment: Erythromycin 500mg qid x 7d, Ceftriaxone 250mg x 1 IM
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Alternatives: Azithromycin x 2gm x 1 dose or Ciprofloxacin 500mg bid x 3d
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All sexual contacts should be treated
Lymphogranuloma Venerium (LGV)
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Caused by serotypes L1, L2, L3 of Chlamydia trachomatis
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Fewer than 1000 cases / year in USA
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Initial lesion after 7 day incubation, on genitalia
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May have papule, eroded or ulcerated nodule, herpetoform lesions, urethritis
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Bubos may develop and become fluctuant; may rupture
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20% of patients present with enlarged lymph nodes; usually resolves in 2-3
months
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Diagnosis. by culture of C. trachomatis
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Treatment: Doxycycline 100mg bid x 21d, ? Azithromycin 2gm x 1
Granuloma Inguinale (Donovanosis)
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Calymmatobacterium granulomatis
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Gram negative rod, endemic to tropics; very rare in USA
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Incubation period usually ~30 (8-80) days
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Nodule progresses to Ulcerating papule then to friable granulation tissue
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Secondary anaerobic infection common
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Pseudo-bubos may form, are actually deep granulomas (lymphadenopathy does
not occur)
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Rule out syphilis, amoebiasis
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Treatment is doxycycline, 100mg bid; alternative TMP/SMX, erythromycin
D. Plague
Yersinia pestis
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Gram negative baccillus, family Enterobacteriaceae
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Carried by fleas
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Harbored in rats and other rodents
Major concern is use as a biological weapon
Incubation period 2-8 days from bite (usually be a flea)
Five cases in USA in 1996 (2 fatalities, 1 each Colorado and Arizona)
Clinical Syndromes
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Bubonic Plague
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Pneumonic Plague
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Septicemic Plague
Bubonic Plague
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Painful, tender, often erythematous lymph nodes (bubonic plague)
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Lymphadenopathy usually develops in groin, axilla or cervical regions
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May progress to pneumonic plague
Pneumonic Plague
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Pneumonia results from inhalation of Y. pestis
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Pneumonia may progress to ARDS and is most common cause of death
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Inoculation period for pneumonic plague is 2-4 days
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Secondary pneumonic plague develops in ~10% of bubonic or septicemic plague
cases
Septicemic Plague
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Full blown sepsis syndrome
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Intravascular coagulopathy common
Diagnosis
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High suspicion is critical
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Organism stain: gram negative coccobaccilus
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Immunoassay: F1 ELISA and dipstick assays are available
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F1 dipstick assay on sputum is positive within ~48 hours of symptoms
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Polymerase chain reaction (PCR) is available in selected laboratories
Therapy
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Streptomycin 15mg/kg q12 hours IM (begin within 24 hours)
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Gentamicin 1.5mg/kg q8 hour IM also effective (preferred in pregnant women)
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Tetracycline also effective 500-1000mg qid PO x 10 days
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Doxycycline IV 200mg initial, then 100mg q12 hours
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Ciprofloxacin 400mg IV bid or 500mg po bid
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Chloramphenicol (for meningitis): 25mg/kg IV initially then 15mg/kg q6 hours
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Multidrug resistant strains reported; sensitive to trimethoprim
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Trimethoprim/sulfamethoxazole (TMP/SMX) is effective but requires longer
to work
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Therapy must be started early on in disease to be effective
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Post-exposure and mass-exposure prophylaxis guidelines have been established
Prevention
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Plague vaccine is available and effective against bubonic plague
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However, vaccine would probably not prevent primary pneumonic plague
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New vaccine for protection against pneumonic plague is under development
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Chemoprophylaxis with sulphadoxine (Fanasil®) 2gm for adults is highly
effective
Lymphedema
Obstruction or obliteration of lymphatic ducts leads to accumulation of
extracellular fluid
Multiple Causes
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Most commonly complication of local and regional therapy for cancer
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Usually in women following lymphadenectomy for breast cancer
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Infection due to filiarisis causing obstruction
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Idiopathic primary lymphedema (may be congenital deformity)
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Yellow Nail Syndrome
Symptoms
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Swelling of affected limb or area
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Massive swelling / obstruction can lead to elephantiasis
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Pain - nerve constriction
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Vascular compromise and ischemia (compartment syndromes may occur)
Physical Therapy
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Also called decongestive lymphatic therapy
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Pysiotherapy with skin massage combined with compression stockings, exercise
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Initiate and maintain reduction in lymphedema
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Reduction in fluid ~40% or more
Warfarin is not effective in patients with lymphedema after breast cancer
evaluation