Lymphadenitis is a nonspecific or specific inflammatory lesion of lymph nodes. Disease is characterized by local soreness and an increase in lymph nodes, headache, malaise, weakness, and an increase in body temperature. Diagnosis is carried out by collecting anamnesis and physical examination; the etiology is clarified by biopsy of the altered lymph node. Treatment is carried out taking into account the isolated pathogen and includes antibiotic therapy, physiotherapy. When an abscess or adenophlegmon is formed, they are opened and drained.
L04 Acute lymphadenitis
The inflammatory reaction of lymph nodes in lymphadenitis is a barrier function of the lymphatic system, which limits the spread of infection through the body. Usually disease occurs as a complication of primary inflammation of any localization. Infectious pathogens (microorganisms and their toxins) penetrate into the regional lymph nodes with a current of lymph that flows from the primary purulent focus. Sometimes, by the time lymphadenitis develops, the primary focus is already eliminated and may remain unrecognized. In other cases, pathology occurs when an infection directly penetrates the lymphatic network through damaged skin or mucosa.
Vascular surgeons, in particular, specialists in the field of phlebology and lymphology, are engaged in the treatment of this disease. With lymphadenitis, damage to the submandibular, cervical, axillary, less often – popliteal, elbow, inguinal lymph nodes occurs more often. There is inflammation of deep lymph nodes (pelvic, iliac).
The causative agents of nonspecific lymphadenitis are usually pyogenic flora – staphylococci and streptococci, as well as toxins and tissue decay products released by them, which penetrate into the lymph nodes by lymphogenic, hematogenic or contact pathways. The primary focus of nonspecific lymphadenitis may be purulent wounds, panaritia, boils, carbuncles, phlegmons, erysipelas, trophic ulcers, thrombophlebitis, caries, osteomyelitis. Local inflammatory processes are more often accompanied by regional lymphadenitis.
Lymphadenitis in children is often associated with inflammatory processes of the ENT organs (influenza, otitis, chronic tonsillitis, sore throat), childhood infections (scarlet fever, diphtheria, mumps), as well as skin diseases (pyoderma, exudative diathesis, infected eczema, etc.). The cause of specific lymphadenitis are pathogens of tuberculosis, syphilis, gonorrhea, actinomycosis, plague, anthrax, tularemia and other infections.
Along the course, disease can be acute and chronic. Acute lymphadenitis undergoes 3 phases in its development – catarrhal, hyperplastic and purulent.
The initial pathological processes in lymphadenitis are characterized by stagnant hyperemia of the skin over an enlarged lymph node, expansion of the sinuses and exfoliation of their endothelium. This is followed by the phenomena of exudation and serous impregnation of the node parenchyma, leukocyte infiltration and proliferation of lymphoid tissue. These structural changes correspond to the catarrhal and hyperplastic stages of lymphadenitis with localization of pathological processes within the capsule of the lymph node. With unfavorable further development, purulent melting of the lymph node occurs with the formation of an encapsulated abscess or the breakthrough of infected contents into the surrounding tissue – the development of paralymphadenitis and adenophlegmon. Ichorous lymphadenitis, which occurs with putrefactive decay of lymph nodes, is characterized by a special severity of the course.
Less common are fibrinous lymphadenitis, characterized by abundant exudation and loss of fibrin, and necrotic form, which develops due to rapid and extensive necrosis of the lymph node. There is also a special form of lymphadenitis – hemorrhagic, characterized by imbibition (impregnation) of the lymph node with blood in anthrax or plague.
With a simple and hyperplastic form, disease can take a chronic course. With lymphadenitis, a single lymph node or several nearby lymph nodes may be involved in inflammation. Depending on the etiology and pathogen, specific and nonspecific form are distinguished.
Acute nonspecific process manifests itself with the soreness of regional lymph nodes and an increase in their size. With catarrhal and hyperplastic forms, enlarged nodes can be easily felt, their soreness is insignificant, general disorders are weakly expressed or absent. Disease often occurs with the involvement of lymphatic vessels – lymphangitis.
In case of suppuration, the node becomes dense and painful, general intoxication develops – fever, loss of appetite, weakness, headache. Local phenomena are increasing – hyperemia and edema in the area of the affected node, the contours of the lymph node become indistinct due to periadenitis. The patient is forced to spare the affected area, because the pain increases with movements. Soon enough, purulent melting of the lymph node occurs and fluctuation becomes noticeable in the infiltrate area.
If the formed abscess is not opened in time, a breakthrough of pus may occur outside or into the surrounding tissues. In the latter case, adenophlegmon develops, which is characterized by a diffuse dense and painful infiltration with separate areas of softening. With the putrefactive form of lymphadenitis, gas crepitation (crunching) is felt during palpation of the node. With destructive processes, general disorders progress – fever, tachycardia, intoxication increase.
Disease in children proceeds violently with high fever, malaise, loss of appetite, sleep disturbance. Possible severe complications may be the generalization of infection with the development of sepsis.
In chronic nonspecific for, the lymph nodes are enlarged, slightly painful, dense, not soldered to the surrounding tissues. The outcome of chronic lymphadenitis is the wrinkling of the nodes due to the replacement of the connective lymphoid tissue. Sometimes the growth of connective tissue causes a disorder of lymph circulation: edema, lymphostasis, elephantiasis.
For specific gonorrheal form, an increase and sharp soreness of the inguinal lymph nodes are typical. Tuberculous form occurs with high fever, severe intoxication, periadenitis, often necrotic changes in nodes. Lymphadenitis in syphilis is characterized by a unilateral moderate increase in the chain of lymph nodes, their unsolicited relationship with each other and with the skin. With syphilitic lymphadenitis, suppuration of the lymph nodes never occurs.
Complications of purulent lymphadenitis can be thrombophlebitis, lymphatic fistulas, septicopiemia. The breakthrough of pus from the tracheobronchial lymph nodes into the bronchi or esophagus leads to the formation of bronchopulmonary or esophageal fistulas, mediastinitis. The development of lymphadenitis can be the starting point for common purulent processes – adenophlegmon and sepsis. The outcome of chronic lymphadenitis may be scarring of the lymph node with connective tissue replacement of lymphoid tissue. In some cases, a violation of lymph outflow and lymphedema may develop.
Recognition of acute nonspecific lymphadenitis of superficial localization is not difficult. At the same time, the anamnesis and the totality of clinical manifestations are taken into account. Complicated forms of lymphadenitis are more difficult to diagnose, occurring with periadenitis and adenophlegmon, involvement of mediastinal fiber and retroperitoneal space. In all cases, it is necessary to establish a primary purulent focus. Differential diagnosis of acute lymphadenitis is carried out with osteomyelitis, phlegmon, suppurated atheroma, etc.
In chronic lymphadenitis, as a rule, a puncture biopsy of the lymph node or its excision with histological analysis is required. This is necessary to distinguish between the chronic form of lymphadenitis and systemic diseases (sarcoidosis), lymphogranulomatosis, leukemia, metastatic lymph node lesions in cancerous tumors, etc.
Diagnosis of specific lymphadenitis is based on a complex of clinical and laboratory data. Tuberculin tests of Mantoux and Pirke are carried out to detect tuberculosis. Microscopic examination of the punctate reveals giant Pirogov-Langgans cells. During chest radiography, tuberculous foci in the lungs can be detected; when examining the soft tissues of the neck, submandibular, axillary, inguinal zones, calcinates in the form of dense shadows are determined in the images.
With syphilitic lymphadenitis, pale treponemas are found in the punctate. Specialists-phthisiologists, venereologists, and infectious diseases specialists are involved in the diagnosis of specific lymphadenitis. If necessary, patients with lymphadenitis undergo ultrasound of lymphatic vessels, CT, MRI of the affected segments, lymphoscintigraphy, radiopaque lymphography.
Catarrhal and hyperplastic acute form is treated conservatively. It is necessary to create rest for the affected area, conduct adequate antibiotic therapy based on the sensitivity of microbial flora, UHF therapy, vitamin therapy. In the purulent process, the autopsy of purulent lymphadenitis, adenophlegmon, drainage and sanitation of the focus according to the principles of purulent wound management is shown. Active detoxification and antibacterial therapy is prescribed.
With chronic nonspecific lymphadenitis, the elimination of the underlying disease that supports inflammation in the lymph nodes is required. Specific lymphadenitis is treated taking into account the etiological agent and the primary process (syphilis, gonorrhea, tuberculosis, actinomycosis, etc.).
Prognosis and prevention
Timely etiotropic treatment of lymphadenitis avoids the spread and generalization of the process. Prevention of lymphadenitis requires the prevention of microtrauma, infection of wounds and abrasions, skin abrasions. Timely treatment of foci of infection (sore throats, dental caries), opening of purulent formations (panaritiums, boils) is also necessary.
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