Clinical Lymphadenopathy in urgent care: evaluation and management Urgent message: Lymphadenopathy is a common presenting issue in urgent care. Most cases are benign, but be on the alert for “red flags” that could signal malignancy. MARIA V. GIBSON, MD, PHD, and DANIEL A. CHERRY, MD Consider how you would manage the following patient presenting with lymphadenopathy. 39-year-old male truck driver presented to the urgent Acare clinic with a 2- to 3-week history of “swollen glands” in both sides of his groin. They were not painful but “tender to touch.” One week prior, he had a flu-like infection with body aches that had resolved. He had no penile discharge, hematuria or dysuria and no fever, night sweats or weight loss. Physical examination, including genitalia, was normal except for palpable inguinal lymph nodes (group of 4, 0.5 to 1.0 cm on the right side and two nodes, 3.0 to 4.0 cm in diameter, on left) that were mobile and tender. The over- lying skin was erythematous and pruritic. Urinalysis was normal, as were tests for gonorrhea, chlamydia, HIV, and reactive plasma reagin, and herpes simplex virus titer. Inguinal skin KOH prep was positive for fungus. The patient was treated with nystatin powder for tinea © Corbis.com cruris. He returned 3 weeks later with persistent pruritic erythema in both sides of his groin and no change in the Lymphadenopathy by Definition size or tenderness of the inguinal lymph nodes. Lymphadenopathy is enlargement of one or more lymph nodes. Lymph nodes are considered to be abnor- Maria Gibson is a physician at Doctor’s Care, Charleston, SC, and mal if one or more is 1.0 cm in diameter, or in the case Associate Professor in the Department of Family Medicine, Medical of an epitrochlear node, > 0.5 cm diameter. Palpability University of South Carolina, Charleston, SC. Daniel Cherry is a hematopathologist and Medical Director of Laboratory Services, Trident of any lymph nodes in the supraclavicular, iliac, Health Care System, and Senior Partner, Lowcountry Pathology or popliteal regions constitutes lymphadenopathy . The Associates, Charleston, SC. condition can be either localized (single node, group of www.jucm.com JUCM The Journal of Urgent Care Medicine | June 2012 9 LYMPHADENOPATHY IN URGENT CARE: EVALUATION AND MANAGEMENT Figure 1. Head and Neck Lymph Nodes and Drainage Distribution Preauricular: Eyelids, lacrimal gland, conjunctiva, pinna, middle ear, upper lip Retroauricular: Posterior side of head, Parotid: Eyelids, lacrimal gland, posterior cutaneous ear conjunctiva, pinna, external ear canal, cutaneous neck, parotid gland Superficial cervical: Submandibular: Lips, cutaneous cheek, Adjoining skin, Parotid gland lacrimal gland, eyelids, conjunctiva, buccal mucosa, lateral and posterior tongue, floor Occipital: Scalp, of the mouth, hard, palate, interior soft upper posterior neck palate, parotid gland, submandibular gland, sublingual gland Submental: Lips, cutaneous cheek, apex Deep cervical: Other lymph of tongue, floor of the mouth, lower gum nodes of the head Pretracheal: Infraglottic larynx, trachea, thyroid Paratracheal: Trachea, thyroid nodes, or region) or generalized. Generalized lym- with generalized lymphadenopathy. phadenopathy is established by enlarged nodes in 2 dis- Ⅲ Malignancies (metastasis, lymphomas, skin neo- tinct anatomic regions. plasms) Ⅲ Infections (infectious mononucleosis, pharyngi- Causes and Associated Conditions tis, cat-scratch disease, mycobacterial, brucellosis, Lymphadenopathy is caused by proliferation of lym- leishmaniasis, tularemia, toxoplasmosis, CMV, phocytes and/or associated monocytic/phagocytic cells HIV, viral hepatitis, TB, syphilis, lymphogranu- (reactive or neoplastic) or by infiltration of metastatic loma venereum, rubella) malignant cells. In the United States, viral and bacter- Ⅲ Autoimmune disorders (systemic lupus erythe- ial infections are the most common etiologies of lym- matosus , rheumatoid arthritis, dermatomyosi- phadenopathy, with infectious mononucleosis (Epstein tis, Sjogren syndrome) Barr virus or EBV) and cytomegalovirus (CMV) more fre- Ⅲ Miscellaneous (sarcoidosis, Kawasaki disease) quently associated with generalized lymphadenopathy Ⅲ Iatrogenic (medications, hyperthyroidism, serum and beta-hemolytic streptococci more frequently asso- sickness, severe hypertrigliceridemia); numerous ciated with localized lymphadenopathy. In developing unusual systemic diseases (pneumoconioses, lyso- countries infections such as HIV, tuberculosis (TB), somal storage diseases, Castleman’s disease, typhoid fever, leishmaniasis, trypanosomiasis, schisto- Kimura’s disease, Rosai-Dorfman disease, Kikuchi’s somiasis and filariasis, and fungal diseases are common lymphadenitis [histiocytic necrotizing lympha- causes of lymphadenopathy. denitis]). The mnemonic acronym “MIAMI” is often used to Adverse drug reactions (allopurinol, atenolol, capto- remember the broad categories of diseases that present pril, cephalosporins, carbamazepine, hydralazyne, peni- 10 JUCM The Journal of Urgent Care Medicine | June 2012 www.jucm.com LYMPHADENOPATHY IN URGENT CARE: EVALUATION AND MANAGEMENT Figure 2. Peripheral Lymph Nodes and Drainage Distribution Supraclavicular: Breast, mediastinum, lungs, esophagus, thorax, abdomen Axillary: Portion of the chest, upper extremity Epitrochlear: 3,4,5 fingers, medial hand, ulnar forearm Inguinal: Scrotum, Paraumbilical: perineum, penis, uterus, vulva Stomach, colon, pancreas, ovaries cillins, primidone, pyrimethamine, phenytoin, quini- generalized lymphadenopathy because of its common dine, trimethoprim/sulfamethoxazole, sulindac) can association with serious systemic diseases (Figures 1 cause generalized lymphadenopathy that may be asso- and 2). Assessment of the size, location, distribution, ciated with a rash, fever, hepatosplenomegaly, jaundice, and character of the lymph nodes is essential. Painful and anemia. A common example of such reactions can and tender lymph nodes are often signs of localized occur in patients a few weeks after taking phenytoin. infection. Inflamed lymph nodes due to local staphylo- coccal and streptococcal infections may progress to Lymphadenopathy Presentation fluctuation, especially in children, and require incision The occurrence of lymphadenopathy is disease-depend- and drainage and antibiotic administration. Multiple ent and the cause often is obvious after a complete his- enlarged cervical nodes that develop over time and tory and physical examination. Patients may present become fluctuant without significant inflammation or with general symptoms: fever, chills, night sweats, tenderness, with or without fever, suggest infection weight loss (infection/lymphoma “B” symptoms), easy with Mycobacterium TB, atypical mycobacteria or Bar- bruising (lymphoma occupying the bone marrow), new tonella henselae (cat scratch disease). skin lesions (infectious or neoplastic), jaundice (hepati- Lymph nodes that are hard on palpation and non- tis), or arthritis (lupus or rheumatoid arthritis). Exposure tender, particularly in older patients and in smokers, are to household pets, diseases, travel history, history of suggestive of metastatic cancer (such as of the orophar- trauma or injury, or new medications provide key infor- ynx, nasopharynx, larynx, thyroid, and esophagus). mation relevant to the diagnosis of lymphadenopathy These patients should be referred to an otolaryngologist At the time of physical examination, all major palpable for upper airway endoscopy. Hard and painless lymph lymph node groups should be examined to evaluate for nodes are also seen with sarcoidosis. Bilateral, 12 JUCM The Journal of Urgent Care Medicine | June 2012 www.jucm.com LYMPHADENOPATHY IN URGENT CARE: EVALUATION AND MANAGEMENT Table 1. Red Flags for Malignancy Red Flags Clinician Alert History Older age, duration of lymphadenopathy > 4 weeks, Increased risk of malignancy absence of infections, exposure to animals and insects, chronic use of medications, personal or family history of malignancy Recurrent fever, night sweats, and unexplained weight loss Suspicious for Hodgkin and non-Hodgkin lymphoma >10% Environmental tobacco, alcohol, and ultraviolet radiation exposure Suspicious for metastatic carcinoma of the lung, Patients who are immunocompromised and HIV-positive esophagus, stomach, liver, or cancers of the head and neck, Increased risk of Kaposi sarcoma and non-Hodgkin and skin. lymphoma Pain in the area of lymphadenopathy Specific finding for Hodgkin lymphoma after even limited alcohol ingestion Exam Lymph nodes that are firm, fixed, circumscribed, and Increased significance for malignant or granulomatous painless disease; further investigation necessary Supraclavicular lymphadenopathy Most likely consistent with malignancy, and should always be investigated and biopsied, even in children Palpable anterior and central axillary lymph nodes with lack Suspicious for metastatic breast adenocarcinoma of infection exposure Antecubital or epitrochlear lymphadenopathy May suggest lymphoma or melanoma Persistent inguinal lymphadenopathy with negative STD Consider investigation for Hodgkin and non-Hodgkin testing and absence of skin infection signs lymphomas, penile, testicular and vulvar carcinomas, and melanoma Any unexplained, non-inguinal Consider specific investigation and/or biopsy lymphadenopathy lasting >4 weeks mobile, nontender lymphadenopathy may be associ- mon in patients with pharyngitis and rubella. Other viral ated with viral infection. Keep in mind that palpable causes of cervical lymphadenopathy include