Lymphatic System

LYMPHATIC SYSTEM ANATOMY AND PHYSIOLOGY - essential to system’s role in immunologic and metabolic processes - major factor in maintenance of fluid balance - production of lymphocytes and antibodies - defend against invasion of microorganisms and other particles with filtration and phagocytosis (ingestion and digestion by cells of solid substances) - plays unwanted role in providing at least one pathway for spread of malignancy - drainage point for right upper body empties into right subclavian vein - has no built-in pumping mechanisms and depends on cardiovascular system for this action - usually occur in groups or chains DEVELOPMENTAL VARIATIONS A. INFANTS AND CHILDREN - immune system and lymphoid system develop at about 20 weeks gestation - enlargement of tonsils in children is not necessarily an indication of problems - before 2 yrs. old, inguinal, occipital and post-auricular nodes are common - after 2, more likely to have significance - supraclavicular nodes are not usually found - - presence is associated with high incidence of malignancy - - always a cause for concern - lymphatic system reaches adult competency during childhood B.

PREGNANT WOMEN - complex changes occur in immune system that are not fully understood - shift from cell-mediated immunity to antibody production/humoral immunity results in increased susceptibility to certain infectious diseases - can lead to remission of autoimmune/inflammatory diseases C.

OLDER ADULTS - number of lymph nodes may diminish and size may decrease with advanced age - nodes are more likely to be fibrotic and fatty - - contributing factor in impaired ability to resist infection

I. A.

SUBJECTIVE ASSESSMENT

LYMPHATIC 1. History of Present Illness - bleeding = site, character, associated symptoms - enlarged nodes (bumps, kernels, swollen glands) = character, associated symptoms,

predisposing factors (infection, surgery, trauma) - swelling of extremity = unilateral, bilateral, intermittent, constant, predisposing factors, associated symptoms, efforts at treatment and their effect 2.

Past Medical History - chronic illness, tuberculosis, blood transfusions, surgery, recurrent

infections 3.

Family History - malignancy, anemia, recent infections, tuberculosis, hemophilia

4.

Developmental Variations a. Infants and Children - recurrent infections = tonsillitis, adenoiditis, bacterial

infections

b. c.

II. A.

- poor growth, failure to thrive - immunization history - maternal HIV infection Pregnant Women - exposure to rubella and other infections - presence of autoimmune disease Older Adults - present or recent infection or trauma - delayed healing

OBJECTIVE ASSESSMENT

LYMPH NODES 1. Inspection and Palpation (can start as soon as you see patient) of Superficial Lymph Nodes - always ask patient if he/she is aware of any lumps - inspect for apparent nodes, edema, erythema, red streaks, and skin lesions - palpate for superficial nodes - try to detect any hidden enlargement, noting consistency, mobility, tenderness, size, and warmth - easily palpable lymph nodes generally are not found in healthy adults - superficial nodes are accessible to palpation but not large or firm are common - when node seems fixed in setting, there is greater cause for concern - explore for signs of possible infection or malignancy - enlarged lymph nodes are characterized according to location, size, shape, consistency, tenderness, movability or juxtaposed to surrounding tissues

- nodes that are enlarged and juxtaposed feel like large mass rather than discrete and are described as matted - note if there is tenderness on touch or rebound - nodes that are large, fixed or matted, inflamed or tender indicate a problem - tenderness is almost always indicative of inflammation (cancerous nodes are not usually tender) - note degree of discoloration or redness - note any unusual increase in vascularity heat or pulsations - with bacterial infection, nodes may become warm or tender to the touch, matted and much less discrete - nodes to which a malignancy has spread are not usually tender - vary greatly in size - are sometimes discrete, matted and firmly fixed, tend to be harder than expected - masses anterior to sternocleidomastoid muscle are benign - those posterior may be malignant - in tuberculosis, nodes are usually “cold” (actually body temperature), soft, matted, and often not tender or painful 2.

Head and Neck - lightly palpate entire neck for nodes - bending pt’s head slightly forward or to side will ease taut tissues - feel for nodes on the head in following sequence: • occipital nodes at base of skull • postauricular nodes • preauricular nose just in front of ear • parotid and retropharyngeal (tonsillar) nodes at angle of mandible • submandibular (submaxillary) nodes halfway between angle and tip of mandible • submental nodes in midline behind tip of mandible - then move down neck as follows: • superficial, anterior cervical nodes • posterior cervical nodes • cervical nodes • supraclavicular areas - detection should always be considered a cause for concern - supraclavicular nodes are commonly the sites of metastatic disease because they are located at the end of the upper “drainage” system

3.

Developmental Variations a. Infants and Children

- commonly find small, firm, discrete, and movable nodes that are neither warm nor tender located in occipital, postauricular, cervical, and inguinal chains - not unusual to find enlarged postauricular and occipital nodes in children younger than 2 - if nodes have grown rapidly and are suspiciously large, mildly painful, or fixed to contiguous tissues and relatively immovable, investigate further - excessive enlargement may obstruct nasopharynx, increasing risk of sleep apnea and on rare occasions, pulmonary hypertension mumps = characterized by somewhat painful swelling of parotid glands unilaterally or bilaterally, and occasionally by swelling and tenderness of salivary glands along mandible - swelling can obscure angle of jaw and may appear on inspection - cervical adenitis does not ordinarily obscure angle of jaw

III.

COMMON ABNORMALITIES

A.

ACUTE LYMPHANGITIS- inflammation of one or more lymphatic vessels - characterized by pain, feeling of malaise and illness, and possibly fever - red streak following course of lymphatic collecting duct - appears as tracing of rather fine lines streaking up extremity - slightly indurated and palpable - look distal for sites of infection, particularly interdigitally

B.

ACUTE SUPPURATIVE LYMPHADENITIS – node is usually quite firm and tender - overlying tissue becomes edematous and skin appears erythematous, usually within 72 hours - mycobacterial adenitis is characterized by inflammation without warmth that may or may not be slightly tender - causes include group a beta-hemolytic streptococci and coagulasepositive staphylococci C. NON-HODGKIN LYMPHOMA – malignant neoplasms of lymphatic system and reticuloendothelial tissues are well defined and solid - occur most often in lymph nodes, spleen, and other sites where lymphoreticular cells are found - may be localized in posterior cervical or may become matted, crossing into anterior

D. HODGKIN DISEASE - malignant lymphoma that occurs in the young of all races, generally in late adolescence and young adulthood - males are twice as likely to develop - commonly painless enlargement of cervical nodes, generally asymmetric and inexorably progressive - occasionally, pressure will produce symptoms that prompt pt to seek medical care - nodes are sometimes matted and generally feel very firm, almost rubbery - occasionally enlarged with size fluctuating E. EPSTEIN-BARR VIRUS MONONUCLEOSIS – infectious mononucleosis that occurs at almost any age but is most common in adolescents and young adults - symptoms include pharyngitis and, usually, fever, fatigue, and malaise - splenomegaly, hepatomegaly and/or a rash may be noted - may be generalized but more commonly felt in anterior and posterior cervical chains - vary in firmness and generally discrete and occasionally a bit tender F.

STREPTOCOCCAL PHARYNGITIS – fairly common - symptoms include sore throat and often a runny nose with accompanying headache, fatigue, and abdominal pain - anterior cervical nodes are commonly felt - - tending to be somewhat firm, discrete and quite often tender - diagnosis is not ensured without a throat culture G. HERPES SIMPLEX – can cause discrete labial and gingival ulcers, high fever, and enlargement of anterior cervical and submandibular nodes - firm, quite discrete, movable, and tender - fever is often high - frequency of condition and symptoms are generally sufficient to establish diagnosis H. CAT SCRATCH DISEASE – most common cause of chronic lymphadenopathy in children - diagnosis can be made in presence of nodal enlargement lasting longer than 3 wks, accompanied by primary lesion of skin or eye and following an interaction with a cat, a cat scratch, or cat lick on break in skin - may be a papule or pustule that may or may not subside over a short period of time - tender nodes are commonly found in the area of the head, neck, and axillae - nodes can be very large

- lymphadenopathy can last for 2 – 4 mos. or even longer, making more serious malignant disease I. AIDS – acquired immune deficiency syndrome characterized by dysfunction of cell-mediated immunity - manifested as development of recurrent, often severe, opportunistic infections - initial symptoms include lymphadenopathy, fatigue, fever, and weight loss - in children, a prolonged clinical latent period, but initial signs may include neurodevelopmental problems with loss of developmental milestones, a parotid enlargement simulating mumps, anemia and thrombocytopenia, chronic diarrhea, and recurrent infections - CD4+ T-lymphocyte count of less than 14% is significant marker for HIVrelated immunosuppression J. HIV SEROPOSITIVITY – HIV antibodies not yet developed sequelae of recurrent infections and neoplastic disease - warning signs and symptoms may include severe fatigue, malaise, weakness, persistent unexplained weight loss, persistent lymphadenopathy, feveres, arthralgias, and persistent diarrhea K. LYMPHEDEMA – congenital lymphedema is hypoplasia and maldevelopment of lymphatic system, resulting in swelling and often grotesque distortion of extremities - acquired lymphedema results from trauma to ducts of regional lymph nodes (particularly axillary and inguinal) after surgery or metastasis - obstruction and infection block lymphatic ducts - does not pit, and overlying skin will eventually thicken and feel tougher than usual - congenital is usually apparent at birth and most often involves the legs L. ELEPHANTIASIS – massive accumulation of lymphedema throughout body that results from widespread inflammation and obstruction of lymphatics by filarial worms, Wuchereria bancrofti or Brugia malayi - adequate drainage is prevented and pt is more susceptible to infection, cellulites, and fibrosis