Should inguinal lymph nodes be palpable

Patients with localized lymphadenopathy should be evaluated for etiologies typically associated with the region involved according to lymphatic drainage patterns. Generalized lymphadenopathy, defined as two or more involved regions, often indicates underlying systemic disease. Risk factors for malignancy include age older than 40 years, male sex, white race, supraclavicular location of the nodes, and presence of systemic symptoms such as fever, night sweats, and unexplained weight loss.

Palpable supraclavicular, popliteal, and iliac nodes are abnormal, as are epitrochlear nodes greater than 5 mm in diameter. The workup may include blood tests, imaging, and biopsy depending on clinical presentation, location of the lymphadenopathy, and underlying risk factors. Biopsy options include fine-needle aspiration, core needle biopsy, or open excisional biopsy.

Antibiotics may be used to treat acute unilateral cervical lymphadenitis, especially in children with systemic symptoms. Corticosteroids have limited usefulness in the management of unexplained lymphadenopathy and should not be used without an appropriate diagnosis.

Lymphadenopathy refers to lymph nodes that are abnormal in size e. Palpable supraclavicular, popliteal, and iliac nodes, and epitrochlear nodes greater than 5 mm, are considered abnormal. Hard or matted lymph nodes may suggest malignancy or infection. In primary care practice, the annual incidence of unexplained lymphadenopathy is 0. Enlarge Print. Ultrasonography should be used as the initial imaging modality for children up to 14 years presenting with a neck mass with or without fever.

Computed tomography should be used as the initial imaging modality for children older than 14 years and adults presenting with solitary or multiple neck masses. In children with acute unilateral anterior cervical lymphadenitis and systemic symptoms, empiric antibiotics that target Staphylococcus aureus and group A streptococci may be given.

Corticosteroids should be avoided until a definitive diagnosis of lymphadenopathy is made because they could potentially mask or delay histologic diagnosis of leukemia or lymphoma. Fine-needle aspiration may be used to differentiate malignant from reactive lymphadenopathy.

Bacterial: brucellosis, cat-scratch disease Bartonella , chancroid, cutaneous infections staphylococcal or streptococcal , lymphogranuloma venereum, primary and secondary syphilis, tuberculosis, tularemia, typhoid fever. Granulomatous: berylliosis, coccidioidomycosis, cryptococcosis, histoplasmosis, silicosis. Viral: adenovirus, cytomegalovirus, hepatitis, herpes zoster, human immunodeficiency virus, infectious mononucleosis Epstein-Barr virus , rubella.

Other: fungal, helminthic, Lyme disease, rickettsial, scrub typhus, toxoplasmosis. Angiofollicular lymph node hyperplasia Castleman disease , histiocytosis, Kawasaki disease, Kikuchi lymphadenitis, Kimura disease, sarcoidosis. Information from references 2 and 3. Factors that can assist in identifying the etiology of lymphadenopathy include patient age, duration of lymphadenopathy, exposures, associated symptoms, and location localized vs. Table 2 lists common historical clues and their associated diagnoses.

Fever, night sweats, weight loss, or node located in supraclavicular, popliteal, or iliac region, bruising, splenomegaly. CBC, nodal biopsy or bone marrow biopsy; imaging with ultrasonography or computed tomography may be considered but should not delay referral for biopsy.

Fever, chills, malaise, sore throat, nausea, vomiting, diarrhea; no other red flag symptoms. Bacterial or viral pharyngitis, hepatitis, influenza, mononucleosis, tuberculosis if exposed , rubella.

Limited illnesses may not require any additional testing; depending on clinical assessment, consider CBC, monospot test, liver function tests, cultures, and disease-specific serologies as needed.

Rabbits, or sheep or cattle wool, hair, or hides. Undercooked meat. Antinuclear antibody, anti-doubled-stranded DNA, erythrocyte sedimentation rate, CBC, rheumatoid factor, creatine kinase, electromyography, or muscle biopsy as indicated. Information from reference 2. About one-half of otherwise healthy children have palpable lymph nodes at any one time. In adults and children, lymphadenopathy lasting less than two weeks or greater than 12 months without change in size has a low likelihood of being neoplastic.

Environmental, travel-related, animal, and insect exposures should be ascertained. Chronic medication use, infectious exposures, immunization status, and recent immunizations should be reviewed as well. Table 3 lists medications commonly associated with lymphadenopathy. An occupational history that includes mining, masonry, and metal work may elicit work-related etiologies of lymphadenopathy, such as silicon or beryllium exposure.

Asking about sexual history to assess exposure to genital sores or participation in oral intercourse is important, especially for inguinal and cervical lymphadenopathy. Finally, family history may identify familial causes of lymphadenopathy, such as Li-Fraumeni syndrome or lipid storage diseases.

Lymphadenopathy and malignancy. Am Fam Physician. A thorough review of systems aids in identifying any red flag symptoms. Arthralgias, muscle weakness, and rash suggest an autoimmune etiology.

Constitutional symptoms of fever, chills, fatigue, and malaise indicate an infectious etiology. Overall state of health and height and weight measurements may help identify signs of chronic disease, especially in children.

Figure 1 , Figure 2 , and Figure 3 demonstrate typical lymphatic drainage patterns, as well as common etiologies of lymphadenopathy in these regions. Finally, abdominal examination focused on splenomegaly, although rarely associated with lymphadenopathy, may be useful for detecting infectious mononucleosis, lymphocytic leukemias, lymphoma, or sarcoidosis. The quality and size of lymph nodes should be assessed.

Lymph node qualities include warmth, overlying erythema, tenderness, mobility, fluctuance, and consistency. A painless, hard, irregular mass or a firm, rubbery lesion that is immobile or fixed may represent a malignancy, although in general, qualitative characteristics are unable to reliably predict malignancy.

Painful or tender lymphadenopathy is nonspecific and may represent possible inflammation caused by infection, but it can also be the result of hemorrhage into a node or necrosis. Morland B. Arch Dis Child.

When to perform biopsies of enlarged peripheral lymph nodes in young patients. Pathology of peripheral lymph node biopsies in Kane, Northern Nigeria. Ann Afr Med. Histopathologic diagnoses of lymphadenopathy in children in Jos, Nigeria. Niger Postgrad Med J. Lymph node biopsies: a hospital based retrospective study.

Adelusola KA. Non malignant peripheral lymphadenopathy in Nigerians. West Afr J Med. Peripheral lymphadenopathy in Nigerian adults. J Pak Med Assoc. Diagnostic aspects of cervical lymphadenopathy in children in the developing world: a study of 1, surgical specimens. Pediatr Surg Int. Aetiology of peripheral lymphadenopathy in adults: analysis of cases seen at a tertiary care teaching hospital in southern India. Natl Med J India. The profile of lymphadenopathy in adults and children.

Med J Malaysia. Unexplained lymphadenopathy in family practice. An evaluation of the probability of malignant causes and the effectiveness of physicians' workup. J Fam Pract. Ahuja AT, Ying M. Sonographic evaluation of cervical lymph nodes. Richner S, Laifer G.

Peripheral lymphadenopathy in immunocompetent Adults. Swiss Med Wkly. Rapid access multidisciplinary lymph node diagnostic clinic: analysis of patients. Br J Cancer. Lymphadenopathy and malignancy. Chamyal PC, Sabarigirish K. Clinico-pathological correlation study of cervical lymph node masses. Histopathology of lymphadenopathy in a tropical country. East Afr Med J. Tuberculosis in HIV-infected patients: a comprehensive review.

Clin Microbiol Infect. Importance of human immunodeficiency virus-associated lymphadenopathy and tuberculous lymphadenitis in patients undergoing lymph node biopsy in Zambia. Br J Surg.

Tuberculous lymphadenitis. J Assoc Physicians India. Luzuriaga K, Sullivan JL. Infectious Mononucleosis. N Engl J Med. In: Fletcher J, Bralow L, editors. Practical Strategies in Pediatric Diagnosis and Therapy. Louis: WB Saunders Co; Frequency and clinicopathologic correlation of different types of non Hodgkin's lymphoma according to WHO classification.

Hurt C, Tammaro D. Diagnostic Evaluation of Mononucleosis-Like Illnesses. Am J Med. Kassutto S, Rosenberg ES. Clin Infect Dis. Investigation of primary human immunodeficiency virus infection in patients who test positive for heterophile antibody.

Epidemiology of Extrapulmonary Tuberculosis in the United States, Mayo Clin Proc. Karnath BM. Approach to the patient with lymphadenopathy. Hospital physician. Yonova D. Pruritus in certain internal diseases. Diagnostic approach to lymph node enlargement. Predictors of malignancy in childhood peripheral lymphadenopathy.

J Pediatr Surg. Assessment of lymphadenopathy in children. Pediatr Clin North Am. Cervical lymphadenitis: etiology, diagnosis and management. Curr Infect Dis Rep. Kunitz G. An approach to peripheral lymphadenopathy in adult patients. West J Med. Isaacs D. Evidence-Based Pediatric Infectious Diseases. New Jersey: Blackwell; Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid.

Am J Surg. Clinical picture of primary HIV infection presenting as a glandular-fever-like illness. Reactive hyperplasia with giant follicles in lymph node lesions from systemic lupus erythematosus patients. Report of three cases. Haque Au, Aan Nu. Leukemoid Reaction: Unusual Causes.

International Journal of Pathology. Esen G. Ultrasound of superficial lymph nodes. Eur J Radiol. Distinction between benign and malignant causes of cervical, axillary, and inguinal lymphadenopathy: value of Doppler spectral waveform analysis. Mountford RA, Atkinson P. Doppler ultrasound examination of pathologically enlarged lymph nodes. Br J Radiol. Role of image-guided core-needle biopsy in the management of patients with lymphoma.

J Clin Oncol. Differentiation of benign and malignant cervical lymph nodes with color Doppler sonography. A thorough review of systems is important in the evaluation of peripheral lymphadenopathy. Constitutional symptoms such as fatigue, malaise, and fever, often associated with impressive cervical lymphadenopathy and atypical lymphocytosis, are seen most commonly with mononucleosis syndromes.

Symptoms such as arthralgias, muscle weakness, or unusual rash may indicate the possibility of autoimmune diseases such as rheumatoid arthritis, lupus erythematosus, or dermatomyositis.

More specific review questions, such as whether pain occurs in the area of lymphadenopathy after even limited alcohol ingestion, may bring out a rare but fairly specific finding of a neoplasm such as Hodgkin's lymphoma.

The physical examination should be regionally directed by knowledge of the lymphatic drainage patterns Figures 1 through 3 and should include a complete lymphatic examination looking for generalized lymphadenopathy.

Skin should be examined for unusual lesions that suggest malignancy and for traumatic lesions, which can be sites of infectious inoculation.

Splenomegaly, while rarely associated with lymphadenopathy, focuses the differential on a limited number of disorders, most commonly infectious mononucleosis, 8 but also the lymphomas, the lymphocytic leukemias, and sarcoidosis.

Palpable cervical lymph nodes, which are commonly appreciable throughout childhood, were noted in 56 percent of adult physicals in one outpatient primary care study, 12 although the incidence declined with age. The most common cause of cervical lymphadenopathy is infection, which in children is typically an acute and self-limited viral infection. While most cases resolve quickly, some entities such as atypical mycobacteria, cat-scratch disease, toxoplasmosis, Kikuchi's lymphadenitis, sarcoidosis, and Kawasaki's syndrome can create persistent lymphadenopathy for many months, and may be confused with neoplasms.

Among this group, supraclavicular nodes are the most likely to be malignant, and should always be investigated, even in children. Because the upper extremities that axillary lymph nodes drain are commonly exposed to local infection and injury, most axillary lymphadenopathy is nonspecific or reactive in etiology. Infectious sources of prolonged lymphadenopathy such as toxoplasmosis, tuberculosis, and mononucleosis rarely manifest with lymphadenopathy alone, 8 and persistent lymphadenopathy is less commonly found in the axillary nodes than in the inguinal chain.

Breast adenocarcinoma often metastasizes initially to the anterior and central axillary nodes, which may be palpable before discovery of the primary tumor. Hodgkin's and non-Hodgkin's lymphomas rarely manifest solely or initially in the axillary nodes, 17 although this can be the first region discovered by the patient. Antecubital or epitrochlear lymphadenopathy can suggest lymphoma, or melanoma of the extremity, which first metastasizes to the ipsilateral regional lymph nodes.

Inguinal lymphadenopathy is common, with nodes enlarged up to 1 to 2 cm in diameter in many healthy adults, particularly those who spend time barefoot outdoors. Infrequently, Hodgkin's lymphomas first present in this area, 11 , 17 as do non-Hodgkin's lymphomas.

Penile and vulvar squamous cell carcinomas, the lymphomas, and melanoma also can occur with lymphadenopathy in this area. When the overlying skin is involved, testicular carcinoma may lead to inguinal lymphadenopathy, 20 which is present in 58 percent of patients diagnosed with penile or urethral carcinoma.

Generalized lymphadenopathy, defined as lymphadenopathy found in two or more distinct anatomic regions, is more likely than localized adenopathy to result from serious infections, autoimmune diseases, and disseminated malignancy.

It usually merits specific testing. Common benign causes include adenoviral illness in children, mononucleosis, and some pharmaceuticals, and these can usually be identified with a careful history and examination.

Generalized adenopathy infrequently occurs in patients with neoplasms, but it is occasionally seen in patients with leukemias and lymphomas, or advanced disseminated metastatic solid tumors.

Hodgkin's lymphoma and most metastatic carcinomas typically progress through nodes in anatomic sequence. Patients who are immunocompromised and those with AIDS have a wide differential for generalized lymphadenopathy, including early human immunodeficiency virus infection, activated tuberculosis, cryptococcosis, cytomegalovirus, toxoplasmosis, and Kaposi's sarcoma, which can present with lymphadenopathy before visible skin lesions appear.

Lymph nodes that are hard and painless have increased significance for malignant or granulomatous disease and typically merit further investigation. For example, the nodes of nodular sclerosing Hodgkin's lymphoma are firm, fixed, circumscribed, and rubbery.

This is in contrast to viral infection, which typically produces hyperplastic nodes that are bilateral, mobile, nontender, and clearly demarcated. Painful or tender lymphadenopathy is non-specific but typically represents nodal inflammation from an infection.

In rare cases, painful or tender lymphadenopathy can result from hemorrhage into the necrotic center of a neoplastic node or from pressure on the nodal capsule caused by rapid tumor expansion.

Lymphadenopathy is classically described as a node larger than 1 cm, although this varies by lymphatic region. Palpable supraclavicular, iliac, or popliteal nodes of any size and epitrochlear nodes larger than 5 mm are considered abnormal. Two series 8 , 13 reported maximum diameters of more than 2 cm and 1. Increasing size and persistence over time are of greater concern for malignancy than a specific level of nodal enlargement.

Using the factors above as guidance, a thorough history and physical examination should allow physicians to categorize individual cases of lymphadenopathy according to the algorithm in Figure 4. Specific testing is indicated if the history and examination suggest autoimmune or more serious infectious diseases Table 1. However, definitive diagnosis is only obtained from biopsy. Algorithm for the evaluation of peripheral lymphadenopathy. Adapted with permission from Ferrer R.

Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician ; The most difficult task for the primary care physician occurs when the initial history and physical examination are not suggestive of a diagnosis that can be pursued with specific testing.

Use of a short course of antibiotics or corticosteroids in the patient with unexplained lymphadenopathy is common. However, there is no evidence to support this practice, which should be avoided because it may hinder or delay diagnosis.

The patient's level of concern should be addressed early and often, with provocative questioning, if necessary. The first step in evaluating unexplained lymphadenopathy involves reviewing the patient's medications Table 2 1 , 8 , 19 , considering unusual causes of lymphadenopathy Table 3 1 , 8 , 19 , and reconsidering the risk factors for neoplasm discussed earlier. If a diagnosis is not suggested, and the patient is deemed low risk for neoplasm, then regional lymphadenopathy can be safely observed.

Given the number of serious causes of generalized lymphadenopathy, a careful search for clues to autoimmune or infectious etiology is essential, and screening laboratory tests for several difficult diagnoses that could present with lymphadenopathy prior to other symptoms may be warranted before observation. Information from references 1 , 8 , and A complete lymph node exam includes an examination of the spleen. The 25 The 25 Visit the Abraham Verghese Interviews Dr. Jerome Kassirer on New Book Signs of Scleroderma can-improv-help-doctors conversation-about-bedside-medicine-gains-momentum.

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