swollen lymph nodes
Introduction
Introduction Lymph nodes are important immune organs in the human body. A normal person has about 500-600 lymph nodes. Lymph nodes can be divided into superficial lymph nodes and deep lymph nodes according to their location. The lymph nodes examined in clinical practice are mainly superficial lymph nodes. Deep lymphadenopathy has no performance in the early stage, and it needs to undergo some special tests, such as lymphangiography and radionuclide scanning. Normal lymph nodes are more than 0.2~0.5cm in diameter, often distributed in groups, soft in texture, smooth in surface, no tenderness, no adhesion to surrounding tissues, except for submandibular, groin, underarm, etc., can touch 1 or 2, Generally not easy to reach. Lymph nodes are swollen due to inflammation or tumors. Each group of lymph nodes collects lymph in the corresponding drainage area. Understanding the relationship between the two has important clinical implications for determining the location and nature of the primary lesion. Lymph node enlargement is very common, can occur in any age group, can be seen in a variety of diseases, benign, but also malignant, so it is very important to pay attention to the cause of lymphadenopathy, timely treatment, diagnosis, to avoid mistakes, missed diagnosis.
Cause
Cause
infection
1. Acute infection: bacteria, viruses, rickettsia, etc. can cause lymphadenopathy such as acute cellulitis, upper respiratory tract infection, infectious mononucleosis, ascariasis.
2. Chronic infection: bacteria, fungi, worms, chlamydia, spirulina, filariasis, sexually transmitted diseases, lymph node granuloma, syphilis, AIDS, etc. may also have lymphadenopathy.
Tumor
1. Malignant lymphoma: Hodgkin's disease and non-Hodgkin's lymphoma.
2. Leukemia: acute lymphocytic leukemia, acute non-lymphocytic leukemia, chronic lymphocytic leukemia, chronic myeloid leukemia, plasma cell leukemia, etc. can also lead to lymphadenopathy.
3. Plasma cell tumor: multiple myeloma, primary macroglobulinemia.
4. Abdominal histiocytosis.
5. Tumor metastasis: gastric cancer, liver cancer, breast cancer, nasopharyngeal cancer, etc.
Reactive hyperplasia
1. Necrotizing proliferative lymphadenopathy.
2. Serum disease and serum disease-like reactions.
3. Allergic subsepsis.
4. Systemic lupus erythematosus, rheumatism, etc.
Cellular hyperplasia
1. Langerhan Histiocytosis (histocytosis X): including Letterer-Sive (Hand-Schüller-Christian) disease and bone eosinophilic granuloma.
2. Lipid deposition disease: including sphingomyelinopathy, also known as Niemann-Pick disease, glucocerebroside disease, also known as Gautier disease.
3. Sarcoidosis.
Mechanism
Inflammatory swelling: bacteria, viruses, rickettsia, chlamydia, fungi, spirochetes, protozoa, helminths, etc. caused by acute and chronic lymph node infection, lymph node congestion and edema, lymphocytes and macrophage proliferation, neutrophils, single Infiltration of nucleated cells and plasma cells and even necrosis and granuloma formation, resulting in enlarged lymph nodes with pain. Acute lymphadenitis is usually secondary to infection in the corresponding drainage area. Effective antibiotic treatment can reduce enlarged inflammatory lymph nodes.
Tumor enlargement: whether it is an endogenous tumor originating from lymphoid tissue (such as lymphoma lymphocytic leukemia), or a tumor metastasized from the lymph node (such as breast cancer metastasis to the axillary lymph node, gastric cancer metastasis to the left clavicle Lymph nodes, etc., can be expressed as unlimited proliferation of tumor cells in the lymph nodes, occupying and destroying the normal tissue structure of the lymph nodes, but also causing fibrous tissue proliferation and inflammatory cell infiltration in the lymph nodes, leading to lymphadenopathy. The cancerous tissue easily invades the surrounding lymphatic sinus and medullary sinus of the lymph nodes, and then gradually spreads the entire lymph node, and can penetrate the surrounding tissue through the capsule. Therefore, the cancerous lymph nodes are often hard as stones and relatively fixed.
Reactive hyperplasia: including non-specific reactive lymphocytosis and immunoreactive hyperplasia. Mostly caused by biological factors (bacterial viruses, etc.), chemical factors (drug environment, toxin metabolism, toxic products, etc.) and allergic stimuli, lymphocytes, mononuclear macrophages, lymphocyte filtration, lymphocyte filtration Increased vesicles, lymphocytes proliferating next to follicles, sometimes manifested as necrotic hyperplasia leading to lymphadenopathy.
Histiocytic hyperplasia: There are a large number of histiocytic hyperplasia in the lymph nodes, which is flaky or mesophilic, and may also have granuloma formation, such as Langerhan histiocytosis. In addition, there are a large number of Niemann-Pickz cells in the lymph nodes, and the Gautier cells can also cause lymphadenopathy when they are aggregated, such as Niemann-Pickz disease and Gautier disease.
Examine
an examination
Related inspection
Rabbit infection test anti-nucleosidase test plasma thrombomodulin activity assay TORCH examination bone marrow mononuclear cell system
Physical examination
The inspection should be carried out in a certain order so as not to cause omissions. In order: lymph nodes in front of the ear, behind the ear, mastoid area, suboccipital region, submandibular, axillary lymph node, cervical lymph node group, supraclavicular fossa, armpit, trochlear, groin and axilla. At the time of palpation, attention should be paid to the location, number, size, texture, surface, tenderness, mobility, presence or absence of adhesion of the enlarged lymph nodes, and whether the local skin is red, swollen, or scarred. In acute non-specific lymphadenitis, swollen lymph nodes often have obvious tenderness, local redness, swelling, heat and other acute inflammation. In chronic infections, the generally swollen lymph nodes are mildly painful, medium in texture, and can adhere to each other. If the tissue necrosis occurs in the lymph node tuberculosis, fluctuations can be felt. The lymph nodes of malignant lymphoma are often swollen and the texture is as hard as cartilage. Lymph node metastasis has a rubbery texture around the texture and adheres to the surrounding tissue, making it difficult to push.
When the specimen is found to have enlarged lymph nodes, it should be combined with other positive signs to comprehensively analyze the cause. Neck and submandibular lymphadenopathy with pharyngeal congestion and tonsil enlargement should be considered as acute tonsillitis, lymphadenopathy with jaundice should consider jaundice hepatitis, malignant histiocytosis, leptospirosis, etc., lymphadenopathy with rash More common in some infectious diseases or allergic diseases, systemic lymphadenopathy with fever is seen in infectious mononucleosis, leukemia, lymphoma and so on.
Deep lymphadenopathy is difficult to reach, often due to its swelling and compression of adjacent organs to appear in the corresponding performance. For example, mediastinal lymphadenopathy can compress the superior vena cava caused by obstruction of blood flow in the superior vena cava region, manifested as edema of the head and upper extremities, jugular venous anger Zhang and other superior vena cava compression syndrome; retroperitoneal lymphadenopathy can compress the ureter to cause hydronephrosis, compression of the solar plexus can cause severe and stubborn low back pain, relieve pain in the forward leaning position, and pain in the supine position; Paravertebral lymph node enlargement oppression of the spinal cord can cause paraplegia; lung disease caused by mediastinal lymphadenopathy, compression of the recurrent laryngeal nerve can lead to hoarseness, compression of the esophagus can cause difficulty swallowing.
Laboratory inspection
1. Blood: The total number and classification of peripheral blood leukocytes have certain reference value for judging the cause of lymphadenopathy. Lymph node enlargement with total white blood cell count and neutrophil increase is common in bacterial infection, but the number of white blood cells in some Gram-negative bacilli infections may not be high, but neutrophils often increase. Lymph node enlargement with normal or decreased white blood cell counts and lymphocytosis often consider viral infection, but patients with infectious mononucleosis caused by EB virus infection often have elevated white blood cells in the second week, and often in three weeks. Abnormal lymphocytes (10%-20% or more), eosinophilia were found, suggesting parasitic infection or eosinophilic granuloma. Lymph node enlargement with peripheral blood immature cells is mostly leukemia or cancer. In malignant histiocytosis (malignant group), in addition to fever, hepatosplenomegaly, the tumor often shows a decrease in whole blood cells.
2, bone marrow examination: bone marrow smear cell morphology examination for leukemia, plasma cell tumor, malignant histiocytosis, high snow disease, Niemann - Peak diagnosis is decisive. Bone marrow pathology should be performed if necessary. Although it is difficult to identify the primary site for metastatic cancer, it is decisive for identifying metastatic cancer cells.
3, serological examination: suspected infectious mononucleosis can be done heterophilic agglutination test, the titer of clinical value above 1:80, >1:200 can be diagnosed as infectious mononucleosis. For patients with suspected leptospirosis, agglutination and dissolution tests can be performed, and the titer of more than 1:400 is positive. For patients with suspected sexually transmitted diseases, HlV antibodies and syphilis serological tests can be performed. When suspected SLE and other autoimmune diseases cause reactive lymphadenopathy, the corresponding serological examination should be done.
4, lymph node puncture needle smear examination: lymph node enlargement is more obvious and the position is shallow, you can use a thicker needle for lymph node puncture, with a large negative pressure suction a small amount of content smear examination. This method is simple and easy.
5, lymph node pathological examination: lymph node enlargement is more obvious and the cause is unknown, if there is no surgical contraindications, it is generally necessary to routinely do lymph node biopsy pathological examination, at the same time can do lymph node printing, morphological examination of its diseased cells, than Pathological sections are seen more clearly.
Device inspection
1. Lymphatic angiography: Deep lymph nodes such as pelvic, retroperitoneal, and para-aortic lymph nodes are not easily accessible. Lymphangiography is a special examination method to understand whether it is swollen or not. Lymphangiitis often shows lymph node enlargement, enlargement, and smooth edge. In malignant lymphoma, the internal structure of the enlarged lymph node is destroyed and foamy. The lymph node metastasis of the lymph node metastasis is irregularly worm-like, often with internal Structural filling defect or lymphatic obstruction.
2, radionuclide scanning: radioactive colloids injected into the subcutaneous or interstitial space are phagocytosed by phagocytic cells into the capillary lymphatics, drained to the corresponding lymph nodes, images of lymph nodes and lymphatic channels can be obtained with a Y camera or scanner. Such as injection into the foot 1, 2 toe, after a certain period of time can make the inguinal, extramedullary, iliac total para-aortic lymph nodes and other imaging, for the diagnosis of deep lymphadenopathy and clear swelling nature is important, such as one or more The lymph node image is obviously enlarged, and the radioactivity is increased, mostly lymphoma. If one or more lymph node images are missing or the radioactivity is significantly reduced or significantly delayed, it often indicates the presence of metastases in the lymph nodes.
3, other: X-ray examination, CT examination, B-mode ultrasound, fiber endoscopy, etc., can help to identify the location and nature of the primary lesion.
Diagnosis
Differential diagnosis
Lymph node enlargement is common in 3 cases: 1 benign enlargement, including swelling caused by various infections, connective tissue diseases and allergies. Clinically, it is often benign, and it can be completely recovered within a certain period of time as the cause is removed. 2 malignant enlargement, including lymph node metastasis such as lung cancer, stomach cancer and breast cancer, which are primary lymph nodes, such as lymphoma, lymphocytic leukemia and malignant histiocytosis, and other malignant tumors. Clinically malignant, lymph nodes continue progressive enlargement, if not actively treated, often progressive deterioration. 3 between the benign and malignant swelling, such as vascular primitive immune cell lymph node disease and vascular follicular lymph node hyperplasia. It is often benign at first, and can become malignant and deadly. Therefore, in the determination of lymphadenopathy, the key is to determine the cause and nature, local swelling with obvious pain often prompt infection; progressive painless hyperplasia suggests malignant tumor disease. Bone marrow aspiration, especially lymph node biopsy, can help confirm the diagnosis. The treatment of lymphadenopathy is determined by disease. For example, streptomycin and remi-salt can be used for lymphatic tuberculosis. If it is a malignant lymphoma, it should be combined with chemotherapy. If the cancer is metastatic, the prognosis is extremely poor.
It can be found by touching the submandibular, neck, supraclavicular fossa, axilla, and groin, but swollen lymph nodes in the hilar, mediastinum, retroperitoneum, and mesentery can be found by X-ray, CT, and B-ultrasound. .
