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Evaluation of peripheral lymphadenopathy in adults

Author
Robert H Fletcher, MD, MSc
Section Editor
Laurence A Boxer, MD
Deputy Editor
Lee Park, MD, MPH

INTRODUCTION

Peripheral lymphadenopathy without an obvious cause after the history and physical examination presents a diagnostic dilemma. On the one hand, there are countless potential causes, some of which are severe and treatable. On the other, severe causes are uncommon and the best way to reach a definitive diagnosis is by biopsy, which is invasive and not justified in most cases.

The general approach to the adult patient with lymphadenopathy is reviewed here. The evaluation and differential diagnosis of neck masses, which includes lymphadenopathy and other lesions, is presented separately. (See "Evaluation of a neck mass" and "Differential diagnosis of a neck mass".)

Evaluation and treatment of lymphadenopathy in children is also discussed separately. (See "Peripheral lymphadenopathy in children: Evaluation and diagnostic approach" and "Cervical lymphadenitis in children: Diagnostic approach and initial management" and "Peripheral lymphadenopathy in children: Etiology" and "Evaluation of inguinal swelling in children".)

ANATOMY AND DEFINITIONS

The location of peripheral lymph node groups is shown schematically in the figures (figure 1 and figure 2). Normal lymph nodes are usually less than 1 cm in diameter and tend to be larger in adolescence than later in life. Lymph nodes are often palpable in the inguinal region in healthy people, perhaps because chronic trauma and infection is so common in the lower extremities, and may also be palpable in the neck (particularly submandibular) following head and neck infections.

Distinguishing between localized and generalized lymphadenopathy can help to formulate a differential diagnosis. A clinically useful approach is to classify lymphadenopathy as localized when it involves only one region, such as the neck or axilla, and generalized when it involves more than one region [1].

                                    

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Literature review current through: Nov 2016. | This topic last updated: Thu Jul 03 00:00:00 GMT 2014.
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References
Top
  1. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician 1998; 58:1313.
  2. Libman H. Generalized lymphadenopathy. J Gen Intern Med 1987; 2:48.
  3. Habermann TM, Steensma DP. Lymphadenopathy. Mayo Clin Proc 2000; 75:723.
  4. Datta PG, Hossain MD, Amin SA, et al. Tubercular lymphadenitis - diagnostic evaluation. Mymensingh Med J 2011; 20:233.
  5. Fijten GH, Blijham GH. Unexplained lymphadenopathy in family practice. An evaluation of the probability of malignant causes and the effectiveness of physicians' workup. J Fam Pract 1988; 27:373.
  6. Chau I, Kelleher MT, Cunningham D, et al. Rapid access multidisciplinary lymph node diagnostic clinic: analysis of 550 patients. Br J Cancer 2003; 88:354.
  7. Morgenstern L. The Virchow-Troisier node: a historical note. Am J Surg 1979; 138:703.
  8. de Andrade JM, Marana HR, Sarmento Filho JM, et al. Differential diagnosis of axillary masses. Tumori 1996; 82:596.
  9. Copeland EM, McBride CM. Axillary metastases from unknown primary sites. Ann Surg 1973; 178:25.
  10. Shipchandler TZ, Lorenz RR, McMahon J, Tubbs R. Supraclavicular lymphadenopathy due to silicone breast implants. Arch Otolaryngol Head Neck Surg 2007; 133:830.
  11. Selby CD, Marcus HS, Toghill PJ. Enlarged epitrochlear lymph nodes: an old physical sign revisited. J R Coll Physicians Lond 1992; 26:159.
  12. Zaren HA, Copeland EM 3rd. Inguinal node metastases. Cancer 1978; 41:919.
  13. Gaines H, von Sydow M, Pehrson PO, Lundbegh P. Clinical picture of primary HIV infection presenting as a glandular-fever-like illness. BMJ 1988; 297:1363.
  14. Lai KK, Stottmeier KD, Sherman IH, McCabe WR. Mycobacterial cervical lymphadenopathy. Relation of etiologic agents to age. JAMA 1984; 251:1286.
  15. Spark RP, Fried ML, Bean CK, et al. Nontuberculous mycobacterial adenitis of childhood. The ten-year experience at a community hospital. Am J Dis Child 1988; 142:106.
  16. Hurt C, Tammaro D. Diagnostic evaluation of mononucleosis-like illnesses. Am J Med 2007; 120:911.e1.
  17. Herrada J, Cabanillas F, Rice L, et al. The clinical behavior of localized and multicentric Castleman disease. Ann Intern Med 1998; 128:657.
  18. Rabinowitz MR, Levi J, Conard K, Shah UK. Castleman disease in the pediatric neck: a literature review. Otolaryngol Head Neck Surg 2013; 148:1028.
  19. Nikanne E, Ruoppi P, Vornanen M. Kikuchi's disease: report of three cases and an overview. Laryngoscope 1997; 107:273.
  20. Tsang WY, Chan JK, Ng CS. Kikuchi's lymphadenitis. A morphologic analysis of 75 cases with special reference to unusual features. Am J Surg Pathol 1994; 18:219.
  21. Lin HC, Su CY, Huang CC, et al. Kikuchi's disease: a review and analysis of 61 cases. Otolaryngol Head Neck Surg 2003; 128:650.
  22. Norris AH, Krasinskas AM, Salhany KE, Gluckman SJ. Kikuchi-Fujimoto disease: a benign cause of fever and lymphadenopathy. Am J Med 1996; 101:401.
  23. Chung CJ, Stein L. Kawasaki disease: a review. Radiology 1998; 208:25.
  24. Sallah S, Gagnon GA. Angioimmunoblastic lymphadenopathy with dysproteinemia: emphasis on pathogenesis and treatment. Acta Haematol 1998; 99:57.
  25. Moran CA, Suster S, Abbondanzo SL. Inflammatory pseudotumor of lymph nodes: a study of 25 cases with emphasis on morphological heterogeneity. Hum Pathol 1997; 28:332.
  26. Terrier B, Hummel A, Servais A, et al. An unusual cause of lymph nodes enlargement. Am J Med 2007; 120:e1.
  27. Yong HS, Woo OH, Lee JW, et al. Primary localized amyloidosis manifested as supraclavicular and mediastinal lymphadenopathy. Br J Radiol 2007; 80:e131.
  28. Abuel-Haija M, Hurford MT. Kimura disease. Arch Pathol Lab Med 2007; 131:650.
  29. Kojima M, Nakamura S, Motoori T, et al. Progressive transformation of germinal centers: a clinicopathological study of 42 Japanese patients. Int J Surg Pathol 2003; 11:101.
  30. Ferry JA, Zukerberg LR, Harris NL. Florid progressive transformation of germinal centers. A syndrome affecting young men, without early progression to nodular lymphocyte predominance Hodgkin's disease. Am J Surg Pathol 1992; 16:252.
  31. Hicks J, Flaitz C. Progressive transformation of germinal centers: review of histopathologic and clinical features. Int J Pediatr Otorhinolaryngol 2002; 65:195.
  32. Verma A, Stock W, Norohna S, et al. Progressive transformation of germinal centers. Report of 2 cases and review of the literature. Acta Haematol 2002; 108:33.
  33. Foucar E, Rosai J, Dorfman R. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): review of the entity. Semin Diagn Pathol 1990; 7:19.
  34. Vassilakopoulos TP, Pangalis GA. Application of a prediction rule to select which patients presenting with lymphadenopathy should undergo a lymph node biopsy. Medicine (Baltimore) 2000; 79:338.
  35. Mohan A, Reddy MK, Phaneendra BV, Chandra A. Aetiology of peripheral lymphadenopathy in adults: analysis of 1724 cases seen at a tertiary care teaching hospital in southern India. Natl Med J India 2007; 20:78.
  36. Lee Y, Terry R, Lukes RJ. Lymph node biopsy for diagnosis: a statistical study. J Surg Oncol 1980; 14:53.
  37. Kelly CS, Kelly RE Jr. Lymphadenopathy in children. Pediatr Clin North Am 1998; 45:875.
  38. Slap GB, Brooks JS, Schwartz JS. When to perform biopsies of enlarged peripheral lymph nodes in young patients. JAMA 1984; 252:1321.
  39. Greenfield S, Jordan MC. The clinical investigation of lymphadenopathy in primary care practice. JAMA 1978; 240:1388.
  40. HEINRICH WA, JUDD ES Jr. A critical analysis of biopsy of lymph nodes. Proc Staff Meet Mayo Clin 1948; 23:465.
  41. Brindley P, Miller GV. Analysis of 600 lymph node biopsies. Texas State J Med 1950; 46:230.
  42. Williamson HA Jr. Lymphadenopathy in a family practice: a descriptive study of 249 cases. J Fam Pract 1985; 20:449.
  43. Pangalis GA, Vassilakopoulos TP, Boussiotis VA, Fessas P. Clinical approach to lymphadenopathy. Semin Oncol 1993; 20:570.
  44. Weiss LM, O'Malley D. Benign lymphadenopathies. Mod Pathol 2013; 26 Suppl 1:S88.
  45. Steel BL, Schwartz MR, Ramzy I. Fine needle aspiration biopsy in the diagnosis of lymphadenopathy in 1,103 patients. Role, limitations and analysis of diagnostic pitfalls. Acta Cytol 1995; 39:76.
  46. Hehn ST, Grogan TM, Miller TP. Utility of fine-needle aspiration as a diagnostic technique in lymphoma. J Clin Oncol 2004; 22:3046.
  47. Zardawi IM. Fine needle aspiration cytology in a rural setting. Acta Cytol 1998; 42:899.
  48. Fanny ML, Beyam N, Gody JC, et al. Fine-needle aspiration for diagnosis of tuberculous lymphadenitis in children in Bangui, Central African Republic. BMC Pediatr 2012; 12:191.
  49. Bottles K, McPhaul LW, Volberding P. Fine-needle aspiration biopsy of patients with acquired immunodeficiency syndrome (AIDS): experience in an outpatient clinic. Ann Intern Med 1988; 108:42.
  50. Reid AJ, Miller RF, Kocjan GI. Diagnostic utility of fine needle aspiration (FNA) cytology in HIV-infected patients with lymphadenopathy. Cytopathology 1998; 9:230.
  51. Ellison E, Lapuerta P, Martin SE. Fine needle aspiration (FNA) in HIV+ patients: results from a series of 655 aspirates. Cytopathology 1998; 9:222.
  52. Amador-Ortiz C, Chen L, Hassan A, et al. Combined core needle biopsy and fine-needle aspiration with ancillary studies correlate highly with traditional techniques in the diagnosis of nodal-based lymphoma. Am J Clin Pathol 2011; 135:516.
  53. van den Brekel MW, Castelijns JA. Imaging of lymph nodes in the neck. Semin Roentgenol 2000; 35:42.
  54. Sumi M, Ohki M, Nakamura T. Comparison of sonography and CT for differentiating benign from malignant cervical lymph nodes in patients with squamous cell carcinoma of the head and neck. AJR Am J Roentgenol 2001; 176:1019.
  55. Wang Q, Takashima S, Takayama F, et al. Detection of occult metastatic lymph nodes in the neck with gray-scale and power Doppler US. Acta Radiol 2001; 42:312.
  56. Khanna R, Sharma AD, Khanna S, et al. Usefulness of ultrasonography for the evaluation of cervical lymphadenopathy. World J Surg Oncol 2011; 9:29.
  57. Ying M, Ahuja AT, Evans R, et al. Cervical lymphadenopathy: sonographic differentiation between tuberculous nodes and nodal metastases from non-head and neck carcinomas. J Clin Ultrasound 1998; 26:383.
  58. Steinkamp HJ, Mueffelmann M, Böck JC, et al. Differential diagnosis of lymph node lesions: a semiquantitative approach with colour Doppler ultrasound. Br J Radiol 1998; 71:828.
  59. Wu CH, Chang YL, Hsu WC, et al. Usefulness of Doppler spectral analysis and power Doppler sonography in the differentiation of cervical lymphadenopathies. AJR Am J Roentgenol 1998; 171:503.
  60. Tschammler A, Ott G, Schang T, et al. Lymphadenopathy: differentiation of benign from malignant disease--color Doppler US assessment of intranodal angioarchitecture. Radiology 1998; 208:117.