Lymphadenopathy is an increase in size, as well as a change in the shape of one or a whole group of lymph nodes of different genesis. In most episodes, lymphadenopathy is only a manifestation of the underlying background disease, but without qualitative diagnostic activities and full course of treatment, this pathology can be transformed into other life-threatening conditions and have serious complications.
Causes of lymphadenopathy
Due to the fact that the lymph node, as the main collector of the lymphatic system, functions as a "protector" of the whole human body from the penetration and spread of various infectious agents, any pathological change in its structure, as well as a disruption of function, indicates the development of mass or limited inflammation. Thus, all kinds of infectious diseases sooner or later provoke changes in the lymphatic circulation system, namely create conditions for the development of inflammatory signs in the structure of the lymph node itself.
It does not matter what kind or type of inflammatory agent entered the body (parasitic invasion, pathogens of specific infections, viral damage and even mushroom multiplication), since the mechanism of development of inflammatory changes in the structure of the lymph node in these situations is the same.
Doctors of any specialty should take into account that the use of a long course of antibacterial and antifungal therapy can become a provocateur of the development of a generalized form of lymphadenopathy, the signs of which are independently leveled after the drug is discontinued in the following pharmacological categories: antibacterial drugs of the penicillin and cephalosporins, quinidine derivatives.
The defeat of visceral groups of lymph nodes is most often observed in a specific category of patients suffering from a metastatic form of oncopathology.
Symptoms of lymphadenopathy
This or that form of lymphadenopathy proceeds in varying degrees of intensity and may have specific manifestations, which depend on the individual reactivity of the patient's organism and the presence of background disease, which was the primary cause of pathological changes in the lymph nodes.
It should be borne in mind that in some cases, the lesion of one lymph node (local lymphadenopathy) may have a brighter and more severe symptomatology than changes in the whole group of lymphatic collectors (generalized lymphadenopathy). The most severe is the so-called reactive type of lymphadenopathy, in which the severity of the patient's condition directly depends on the severity of the intoxication-inflammatory syndrome.
The acute period of lymphadenopathy in this situation is accompanied by the development of such symptoms as a hectic type of fever, severe sweating, followed by chills, local soreness and limited hyperemia of the skin in the supposed localization of the lymph node. Attachment of hepatosplenomegaly indicates a worsening of the patient's condition. Provided that the treatment measures are completely absent, in this situation the tissue of the lymph node melts and the rapid spread of the inflammatory elements by the blood current results in the development of generalized sepsis.
In most cases, even with a primary objective examination of a patient with one or another form of lymphadenopathy, an experienced specialist can determine the main clinical criteria that allow one to judge the presence of changes in the lymph node system.
In order to determine the presence of changes in the main groups of lymph nodes, the physician palpates not only the affected area, but also other parts of the trunk in which the lymphatic reservoirs are presumably located. For example, to establish a preliminary diagnosis of "inguinal lymphadenopathy" it is sufficient to perform palpation and compression of the inguinal region, especially the projection of the inguinal ring, since the location of this group of lymph nodes is rather superficial. The defeat of the visceral groups of the lymph nodes can be visualized and established only with the help of the instrumental diagnostic methods used.
First of all, the term "lymphadenopathy" implies a change in the size of the lymph node, which most often changes in the direction of increasing parameters, but when assessing the size of the node, it should be borne in mind that its normal parameters can vary widely, depending on localization. So, the normal size of the inguinal lymph node will be increased for the cervical group of lymph nodes.
In the event that the patient has uncomfortable pain when compressing soft tissues located near the lymph node, the inflammatory nature of the lesion should be assumed. In addition, signs of lymphadenopathy of inflammatory genesis are reddening, an increase in volume and a local increase in the temperature of the skin and soft tissues in the projection of the location of the lymph node.
Important in the differential diagnosis of diseases that provoked the development of lymphadenopathy, has the definition of consistency, the structure of the lymph node and the displacement of it relative to surrounding tissues. Thus, the presence of a dense lymph node or a lymphatic conglomerate of a high density, immobile upon palpation, indicates a development of the neoplastic process or the presence of a specific inflammation (tuberculous lesion).
In addition, it is necessary to take into account the localization of the affected lymph nodes, as for most diseases is characterized by limited damage to one of the groups. For example, inflammatory diseases of the oral cavity in most cases are limited to the damage to the cervical groups of the lymph nodes.
Due to the fact that even the same forms of lymphadenopathy can occur differently in each individual case, a certain algorithm of examination of patients suffering from the pathology of a particular group of lymph nodes is used in medical practice. This screening test consists of specific and general laboratory methods (blood tests for inflammatory changes, titer detection of specific cancer markers), as well as various radiation imaging techniques (standard and contrast radiography, ultrasound scanning, computed tomography).
The most common form of involvement of inflammatory lymph nodes is the lymphadenopathy of the cervical lymph nodes, which is to a greater extent the lot of pediatricians, as it accompanies the course of the main infectious diseases of childhood. Localized these inflammatory changes, usually in the oral cavity or salivary glands, and therefore, the proximity of the location of the cervical group of lymph nodes allows rapid attachment of reactive lymphadenopathy. This type of lymphadenopathy rarely needs specific therapy, and the changes in the lymph nodes themselves are leveled after the root cause of the disease has been eliminated.
The adult category of patients is less affected by this pathology and if there are changes in the cervical groups of the lymph nodes, one should assume a tumor genesis of lymphadenopathy. In this regard, with the primary treatment of a patient with cervical lymphadenopathy, a complete instrumental examination of not only the affected area, but also other organs and systems, is necessary to exclude malignant neoplasms.
The defeat of this or that group of cervical lymph nodes can become an important diagnostic and prognostic sign of various pathological conditions in the body. Thus, an increase in the posterior cervical group of lymph nodes is accompanied by infectious foci localized in the scalp, as well as toxoplasmosis and rubella. Infection of the eyelids and conjunctiva is most often accompanied by an increase in the size of the anterior cervical lymph nodes. And with the existing changes in all groups of lymph nodes, it should be assumed that the patient has lymphoma .
Tuberculosis infection is characterized by a rapid progressive increase in cervical lymph nodes with subsequent suppuration. The supraclavicular group of lymph nodes is extremely scarce and the appearance of this lymphadenopathy should be regarded as an unfavorable prognostic sign (metastatic lesion in the localization of the primary tumor in the thoracic cavity). The epithelial lymph node is affected in sarcoidosis and secondary syphilis , with the increase in nodes being bilateral symmetrical. Unilateral defeat of his most often accompanies the infected lesions of the skin of the upper limb.
Lymphadenopathy of the axillary lymph nodes in the predominant majority of cases is inflammatory. Its development is provoked by the ingestion of nonspecific infectious agents through damaged skin with lymph flow.
In a situation where the patient has signs of an increase in size or a change in the shape of the axillary lymph nodes in the presence of oncological breast disease, mammologists use the term "axillary lymphadenopathy" in their practical activities.
Recently, the world community of surgeons has noted a steady progression of the incidence of axillary form of lymphadenopathy among patients of different ages, race and sex. First of all, such dynamic development of lymphadenopathy is explained by anthropogenic influence, unfavorable ecological situation, and altered mixed infection. Priority groups of microorganisms that are frequent provocators of the development of inflammatory changes in the axillary groups of lymph nodes are pyogenic microorganisms of the coccovian category.
Due to the fact that the axillary group of the lymph nodes is superficially located and is well accessible for surgical intervention, surgical treatment of axillary lymphadenopathy is used in most cases to avoid the development of complications of inflammatory inflammatory lymphadenopathy in the form of development of lymph node melting and formation of signs of sepsis.
Operative benefit in this case consists in opening and adequate sanation of the focus of purulent inflammation with subsequent drainage. Particular attention should be paid to a sufficient length of operative access, allowing to completely remove the areas of purulent fusion with the surrounding unaltered fatty tissue. During the operation, the patient is recommended to inject the first dose of Cephalosporin directly into the altered lymph node, followed by a parenteral course of antibacterial therapy, which in this situation is prophylactic.
In the postoperative period, it is necessary to use medications aimed at eliminating the underlying disease (famciclovir with a viral infection at a dose of 0.25 mg 3 times / day orally, Fluconazole at a daily dose of 200 mg with a fungal lesion, Fansidar with toxoplasmic lymphadenopathy 2 tablets 1 time in Week). Great importance in the period of convalescence should be given to the state of the patient's immunity, in connection with which the basic treatment must be combined with immunomodulatory medications (Roncoleukin in a daily dose of 2 mg orally).
Lymphadenopathy of the mediastinum
Mediastinal lymphadenopathy often accompanies the course of severe specific forms of pulmonary parenchyma of inflammatory genesis, among which the most common pathology is tuberculous lesion.
It should be borne in mind that most patients who are often ill with respiratory and viral diseases, complicated by the attachment of a bacterial infection, have pulmonary lymphadenopathy that is transient. In connection with this, this pathological condition is diagnosed extremely rarely.
The most common cause of the classical variant of mediastinal lymphadenopathy are tumor diseases of structures belonging to one or another mediastinal department. Unfortunately, the clinical manifestations of this form of lymphadenopathy begin to manifest at a late stage of the disease and consist in the appearance of a severe pain syndrome caused by the spread of the tumor substrate into the structures of the nervous tissue. Most often, the pain is one-sided with a typical irradiation of pain in the shoulder region and the upper half of the back. The appearance of pain in the projection of the bones and soft tissues of any site should lead the doctor to the idea of the appearance of distant metastases in the patient.
In addition, the typical clinical manifestations of mediastinal lymphadenopathy are the categories of so-called "compression symptoms" that are observed with a marked increase in the size of the mediastinal neoplasm. In connection with the fact that in one or another part of the mediastinum besides the organs there is a neurovascular bundle, the compression of large vessels of this bundle inevitably provokes the development of hemodynamic disorders (venous hypertension, cardiac rhythm disturbances, headaches and severe dizziness at rest, acrocyanosis and diffuse cyanosis of the skin).
In a situation where enlarged mediastinal lymph nodes exert compressive pressure on the trachea and lumen of the bronchi, the patient begins to show symptoms indicative of respiratory disorders (spastic cough, difficulty breathing, increasing dyspnoea). The patient's complaint about a difficult swallowing act, a constant sensation of "lump in the throat" testifies to the development of the compression effect of lymphadenopathy on the esophagus.
Malignant forms of mediastinal tumors, namely lymphogranulomatosis and lymphoreticocarcinoma, accompanied by the development of mediastinal lymphadenopathy are characterized by the development of all non-specific signs of oncological disease in a person (rapid weight loss, severe weakness and decreased ability to work, hyperhidrosis ).
In a situation where the patient has clinical manifestations that indicate the presence of mediastinal lymphadenopathy, in order to confirm the diagnosis, as well as to identify the cause of this syndrome, it is necessary to conduct radiation examinations of the patient, and if necessary, verification of the diagnosis - puncture biopsy by videotorakoscopy.
The retroperitoneal lymphadenopathy
This form of lesion of the retroperitoneal group of lymph nodes is most often a pathognomonic sign of the patient's tumor lesion of various locations, so the detection of enlarged retroperitoneal lymph nodes in the patient is the basis for a thorough screening examination using specific diagnostic measures.
The main manifestations of lymphadenopathy of retroperitoneal lymph nodes are short-term fever, paroxysmal intense pains in the abdominal cavity, which do not have a clear localization, diarrhea . Most often the lymph nodes of the retroperitoneal space are affected in case of tumor lesion with localization in the organs of any part of the digestive tract, kidneys and less often with testicular tumors.
In some situations, the primary symptom of retroperitoneal lymphadenopathy is the intense pain syndrome in the back caused by the compression of nerve endings. The most reliable way to diagnose this category of lymphadenopathy is magnetic resonance imaging with the use of contrast.
Lymphadenopathy in children
At present, cases of lymphadenopathy in various age categories of patients have significantly increased in pediatric practice, and before changes in lymph nodes were more inflammatory, and in the last decade it is not uncommon for the lymph nodes to be damaged by paraneoplastic processes, which is largely due to an unfavorable ecological situation.
It is necessary to distinguish such concepts as " lymphadenitis ", which is nothing more than an inflammatory-altered lymph node, and "lymphadenopathy", which is an intermediate diagnosis until a reliable diagnosis of the cause of enlargement of the lymph node (scarlet fever, infectious mononucleosis, lymphogranulomatosis).
It should be borne in mind that before the child reaches the age of 12 years, the lymphatic system is considered immature, although the beginning of its formation falls on the early intrauterine period. Such functional immaturity of the structures of the lymphatic system explains the high incidence of lymphadenopathy, which is observed among patients of the children's age category.
When examining a newborn baby, the detection of any palpable lymph nodes indicates an increase in the lymph nodes, since in this age period, lymph nodes are usually not available for palpation. The first year of a child's life is considered critical, since at this age there is a reactive increase in the major lymph nodes of the neck, occipital and inguinal areas. In the more mature age, the criterion for the normal functioning of the lymphatic system, which is observed in the majority of healthy children after three years, is the palpation of not more than three groups of superficial lymph nodes.
If we consider the structure of etiopathogenetic forms of lymphadenopathy, which are observed more or less frequently in pediatrics, then the leading positions are occupied by immune reactive lymphadenopathies arising from various infectious diseases. Equally often in childhood, lymphadenopathy occurs as a result of existing chronic hyperplastic diseases (immunodeficiency) and systemic connective tissue pathologies. Fortunately, the lymphadenopathy of a specific tumor character is no more than 10% in the structure of the overall incidence, however early diagnosis of this type of change is important for predicting the patient's recovery. Very rarely, lymphadenopathy in children is observed with severe allergic reaction and helminthic invasion.
The development of signs of cervical lymphadenopathy is more typical for children with lymphatic-hypoplastic type of constitution, and changes in lymph nodes of the cervical group are always accompanied by the development of inflammatory changes in the oral cavity, as well as an increase in the thymus and spleen. The reactive type of lymphadenopathy of the cervical groups of the lymph nodes is often a manifestation of inflammatory changes in the gums in children with teething. In order to determine the alleged chronic source of infection from which the inflammatory agents have entered a regional lymph node, it is necessary to take into account the direction of the normal flow of the lymphatic fluid from one or another anatomical region.
In a situation where the child has a persistent generalized lymphadenopathy after a month of life, combined with fever, dermatitis , a common oral candidiasis and chronic diarrhea, it should be assumed that the patient has AIDS.
The defeat of lymph nodes by paraneoplastic processes can occur as a primary tumor of the lymphatic system or as a development of secondary metastasis. Malignant form of the tumor process, localized in the lymphatic system, which prevails in childhood, is lymphosarcoma , which primarily affects the mediastinal and mesenteric lymph nodes.
Treatment of lymphadenopathy
The volume of necessary and pathogenetically substantiated medical measures depends on a number of factors (patient age, presence of concomitant signs of infection, assessment of the severity of the patient). The most important factor in choosing the tactics of treating a patient with lymphadenopathy is the qualitative diagnosis of the underlying background disease, which served as a provocateur of changes in a particular group of lymph nodes. Thus, the main branch of the conservative treatment of lymphadenopathy is empirical etiopathogenetic treatment.
Thus, with lymphadenopathy, accompanied by infection of the tissues of the lymph node and surrounding soft tissues, the basis of etiological treatment will be antibacterial agents. Initially, prior to the recognition of the pathogenic flora by the method of determining sensitivity to a particular category of antibacterial drugs of punctate obtained with biopsy of the lymph node, preference should be given to antibiotics of the cephalosporin series (Medaxone 1 million units once a day intramuscularly), as well as fluoroquinolones (Levofloxacin 1 g intravenously). The duration of this therapy is determined by the individual reactivity of the patient's body, as well as the rate of leveling of clinical manifestations and the normalization of the main criteria of the inflammatory reaction in the blood test.
In the case when lymphadenopathy is a manifestation of a system specific disease of infectious nature (tularemia, syphilis), the scheme of antibacterial drug treatment should be largely determined by the underlying pathology.
Due to the fact that the lymphatic tissue is prone to the rapid spread of inflammatory changes, with any form of lymphadenopathy, care should be taken with regard to the local treatment of this pathology (the use of warming compresses, alcohol sprays). The use of these manipulations in the tumor genesis of lymphadenopathy is absolutely contraindicated, since they create conditions for the spread of tumor cells. The only expedient method of local treatment is the treatment of the skin immediately in the location of the affected lymph node with the help of antiseptic agents in the form of ointments (application with Vishnevsky ointment twice a day). However, one should not expect complete recovery with an isolated application of ointment without concomitant antibiotic therapy.
In the case when a patient with limited lymphadenopathy is confirmed to have a tumor genesis of changes in the lymph node by the method of puncture biopsy, a course of chemotherapy is recommended.
If there is a change in the lymph node with purulent contents, the patient shows the use of surgical treatment of lymphadenopathy, carried out according to several basic techniques. The main goal of surgical treatment is opening of the lymph node, removal of purulent contents and establishment of drainage for outflow of the discharge.
In order to stimulate the body's own defense mechanisms, the use of immunomodulating agents is recommended as an additional treatment (Glutoxim 5 mg intramuscularly for 10 days).