A localized cancer that has not extended beyond the margins of the organ involved. A systemic illness is one that affects the entire body, rather than a single organ or body part. Many organs and tissues might be involved in the complex disease process. Some of the most commonly treated systemic disorders internists handle include:.
Influenza — In severe cases, an internist may prescribe an antiviral medication , such as Tamiflu or Relenza, to shorten the illness and prevent serious complications. Diabetes mellitus — Internists help patients monitor blood glucose levels and manage their diet and exercise programs. If needed, oral medications may be prescribed, or insulin used via injections or pump. Hypertension — High blood pressure is often effectively treated with lifestyle changes, but medications may be used to control the condition.
High cholesterol — More than million American adults have unhealthy cholesterol levels, and over 35 million of these individuals have cholesterol levels high enough to put them at risk for heart disease, the number one killer of men and women in the United States.
Internists help patients manage high cholesterol with lifestyle changes and statin medicines if required. Chronic fatigue syndrome — This complicated disorder with an unknown cause manifests as extreme fatigue that does not improve with rest. Rather than depend on a single test to diagnose CFS, internists must perform a variety of medical tests to rule out other similar illnesses. Treatment usually focuses on symptom relief through lifestyle changes and sometimes medications.
Lupus — At least 1. However, the tissue injury may extend into the structures underlying the skin, including the subcutaneous tissue, fascia, muscle or bone. Localized scleroderma skin lesions can get better or even go away. With circumscribed morphea another name for discolored patches of skin , you may have a single oval patch or you may see a few patches of morphea.
The patches vary in size and typically have a red border and a thickened pale-yellow center. These lesions can enlarge when active and then flatten and become asymptomatic with treatment.
Deep circumscribed morphea extends into the subcutaneous tissues. Generalized morphea is seen when there are many patches of morphea greater than four plaques in many anatomical areas trunk, arms, head or neck. They are seen as thick, tight patches that can blend into each other.
Pansclerotic morphea is a severe form of generalized morphea with involvement of most of the body. Linear scleroderma is more common in children 10 and younger. These tight, thick bands can appear on the extremities, the back and front of the trunk, the buttocks or the face. They often appear as a single band in one body area and can be seen mixed with patches of morphea. Linear scleroderma can affect the bones and the muscles. The skin thickening that accompanies systemic scleroderma can cause tightening so there is a loss of flexibility and ease of movement, especially in the fingers.
Facial involvement is common and may be mild or it can reduce facial movements, including decreasing the mouth opening. 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. Head and neck lymphadenopathy can be classified as submental, submandibular, anterior or posterior cervical, preauricular, and supraclavicular.
In children, acute and self-limiting viral illnesses are the most common etiologies of lymphadenopathy. Persistent lymphadenopathy lasting several months can be caused by atypical mycobacteria, cat-scratch disease, Kikuchi lymphadenitis, sarcoidosis, and Kawasaki disease, and often can be mistaken for neoplasms.
Infections or injuries of the upper extremities are a common cause of axillary lymphadenopathy. Common infectious etiologies are cat-scratch disease, tularemia, and sporotrichosis due to inoculation and lymphatic drainage. Absence of an infectious source or traumatic lesions is highly suspicious for a malignant etiology such as Hodgkin lymphoma or non-Hodgkin lymphoma. Breast, lung, thyroid, stomach, colorectal, pancreatic, ovarian, kidney, and skin cancers malignant melanoma can metastasize to the axilla.
Epitrochlear lymphadenopathy nodes greater than 5 mm is pathologic and usually suggestive of lymphoma or melanoma. Inguinal lymphadenopathy, with nodes up to 2 cm in diameter, is present in many healthy adults. It is more common in those who walk outdoors barefoot, especially in tropical regions. Lymphomas, both Hodgkin and non-Hodgkin, typically do not present in the inguinal region.
Inguinal lymphadenopathy is present in about one-half of penile or urethral carcinomas. Generalized lymphadenopathy is the enlargement of more than two noncontiguous lymph node groups.
Benign causes of generalized lymphadenopathy are self-limited viral illnesses, such as infectious mononucleosis, and medications. Other causes include acute human immunodeficiency virus infection, activated mycobacterial infection, cryptococcosis, cytomegalovirus, Kaposi sarcoma, and systemic lupus erythematosus. Generalized lymphadenopathy can occur with leukemias, lymphomas, and advanced metastatic carcinomas.
Figure 4 provides an algorithm for evaluating lymphadenopathy. Findings suggestive of infectious or autoimmune etiologies may require specific testing and treatment as indicated. If malignancy is considered unlikely based on history and physical examination, localized lymphadenopathy can be observed for four weeks. Generalized lymphadenopathy should prompt routine laboratory testing and testing for autoimmune and infectious causes.
Algorithm for evaluating lymphadenopathy. Radiologic evaluation with computed tomography, magnetic resonance imaging, or ultrasonography may help to characterize lymphadenopathy. The American College of Radiology recommends ultrasonography as the initial imaging choice for cervical lymphadenopathy in children up to 14 years of age and computed tomography for persons older than 14 years.
In children with acute unilateral anterior cervical lymphadenitis and systemic symptoms, antibiotics may be prescribed. Empiric antibiotics should target Staphylococcus aureus and group A streptococci. Fine-needle aspiration FNA and core needle biopsy can aid in the diagnostic evaluation of lymph nodes when etiology is unknown or malignant risk factors are present Table 4 4 , 6 , FNA cytology is a quick, accurate, minimally invasive, and safe technique to evaluate patients and aid in triage of unexplained lymphadenopathy.
Combined, they allow cytologic and histopathologic assessment of lymph nodes. False-negative results occur secondary to early or partial involvement of lymph nodes, inexperience with lymph node cytology, unrecognized lymphomas with heterogeneity, and sampling errors.
Regardless, FNA may be a useful triage tool for differentiating benign reactive lymphadenopathy from malignancy. Information from references 4 , 6 , and Open excisional biopsy remains a diagnostic option for patients who do not wish to undergo additional procedures. When selecting nodes for any method, the largest, most suspicious, and most accessible node should be sampled.
Inguinal nodes typically display the lowest yield, and supraclavicular nodes have the highest. This review updates previous articles on this topic by Bazemore and Smucker 2 and Ferrer. Key terms: lymphadenopathy, peripheral, generalized, evaluation, treatment, imaging, management. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Reference lists of retrieved articles were also searched. Search dates: September and July The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.
Air Force Medical Department or the U. Air Force at large. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Heidi L. Reprints are not available from the authors. Unexplained lymphadenopathy in family practice. An evaluation of the probability of malignant causes and the effectiveness of physicians' workup. J Fam Pract. Mayo Clin Proc. Lymphadenopathy in children: refer or reassure? Clinical approach to lymphadenopathy.
Semin Oncol. Diagnosing cancer in the symptomatic patient.
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