You are on page 1of 45

Pendekatan Diagnostik

Limfadenopati
Limfadenopati dan:
pendekatan diagnostik
Limfadenitis

Dr. Norman Djamaluddin, SpPD K- HOM


Sub bagian Hematologi Onkologi Medik
Bagian Penyakit Dalam RSMH Palembang
The Lymphatic System
The body has approximately 600 lymph nodes, but only those
in the submandibular, axillary or inguinal regions may
normally be palpable in healthy people.1 Lymphadenopathy
refers to nodes that are abnormal in either size, consistency
or number. There are various classifications of
lymphadenopathy, but a simple and clinically useful system is
to classify lymphadenopathy as "generalized" if lymph nodes
are enlarged in two or more noncontiguous areas or
"localized" if only one area is involved.
Distinguishing between localized and
generalized lymphadenopathy is important in
formulating a differential diagnosis.
In primary care patients with unexplained
lymphadenopathy, approximately 3/4 of
patients will present with localized
lymphadenopathy and 1/4 with generalized
lymphadenopathy.
Kelenjar getah bening leher

Bazemore AW. Physician 2002;66:2103-10


Kelenjar getah bening aksila

Bazemore AW. Physician 2002;66:2103-10


Kelenjar getah bening inguinal

Bazemore AW. Physician 2002;66:2103-10


Level kelenjar getah bening leher

Level 1 : submental dan


submandibular
Level 2 : upper jugular
Level 3 : middle jugular
Level 4 : lower jugular
Level 5 : posterior
triangle group
Level 6 : anterior triangle
group

Robbins KT. Arch Otolaryngol Head Neck Surg. 2002;128:751-8


Pendekatan diagnosis
limfadenopati

Definisi

Klasifikasi

Etiologi

Pendekatan diagnosis
Definisi

Limfadenopat
Pembesaran kelenjar getah bening dengan ukuran lebih
besar dari 1 cm.
Ferrer R. Am Fam Physician 1998;58:1315
atau
Abnormalitas ukuran atau karakter kelenjar getah bening
Bazemore AW. Physician 2002;66:2103-10

Limfadenits
Radang pada kelenjar getah bening yang disertai dengan
tanda-tanda inflamasi.
Elizabeth Partridge,
http://emedicine.medscape.com/article/960858-overview
Klasifikasi

Limfadenopati Limfadenopati
lokalisata generalisata

Limfadenopati limfadenopati
pada 1 regio pada 2 atau lebih
regio anatomi
yang berbeda
Malignancies Etiologi

Infections

unusual condition
Autoimmune
MIAMI
Bazemore AW. Physician 2002;66:2103-10
Iatrogenic
Etiologi : Malignancies

Lekemia

Limfoma

Neoplasma kulit

Kaposi sarkoma

Metastase
Etiologi : Infectious
Brucellosis

Cat-scratch disease

CMV

HIV, infeksi primer

Limfogranuloma venerium

Mononukleosis

Faringitis

Rubela
Etiologi : Autoimun

Lupus eritematosis sistemik



Artritis rematoid

Dermatomiositis

Sindroma Sjogren
Etiologi :Miscellaneous/unusual

Penyakit Kawasaki
Sarkoidosis

Bazemore AW. Physician 2002;66:2103-10


Etiologi : SHAK
H
S
Hipertiroidisme
Sarcoidosis
Histiositosis
Silicosis
Hipertrigliseridemia
Storage disease

Bazemore AW. Physician 2002;66:2103-10


Etiologi : Iatrogenic

Alopurinol Pirimidone

Atenolol Pirimetamine

SerumCaptopril
sickness Kuinidin

Obat obatan :
Carbamazepine Trimetoprim sulfametoksazole
Hydralazine Sulindac
Penisilin Fenitoin

Bazemore AW. Physician 2002;66:2103-10


Pendekatan diagnosis
limfadenopati

Definisi

Klasifikasi

Etiologi

Pendekatan diagnosis
Pendekatan diagnosis
Anamnesa
Umur penderita dan lamanya
limfadenopati
628 penderita, penyebab benign dan self
limiting :
79% penderita berusia kurang dari
30 tahun
59% penderita antara 31-50 tahun
39% penderita di atas 50 tahun.

Ferrer R. Am Fam Physician 1998;58:1315


Bazemore AW. Physician 2002;66:2103-10
.
Pendekatan diagnosis

Anamnesa
Umur penderita dan lamanya
limfadenopati :
Risiko keganasan sebagai
penyebab limfadenopati :
usia 40 tahun atau lebih : 4%

usia di bawah 40 tahun : 0,4%.


Ferrer R. Am Fam Physician 1998;58:1315
Bazemore AW. Physician 2002;66:2103-10
Pendekatan diagnosis

Anamnesa
Umur penderita dan lamanya
limfadenopati
limfadenopati yang berlangsung
kurang dari 2 minggu atau lebih dari 1
tahun tanpa progresivitas ukuran
mempunyai kemungkinan sangat kecil
disebabkan keganasan
Ferrer R. Am Fam Physician 1998;58:1315
Bazemore AW. Physician 2002;66:2103-10
Pendekatan diagnosis

Anamnesa :

Paparan
Simptom yang menyertai
History

First, are there localizing symptoms or signs to suggest


infection or neoplasm in a specific site?
Second, are there constitutional symptoms such as fever,
weight loss, fatigue or night sweats to suggest disorders such
as tuberculosis, lymphoma, collagen vascular diseases,
unrecognized infection or malignancy?
History

Third, are there epidemiologic clues such as occupational


exposures, recent travel or high-risk behaviors that suggest
specific disorders?
Fourth, is the patient taking a medication that may cause
lymphadenopathy? Some medications are known to
specifically cause lymphadenopathy (e.g., phenytoin ), while
others, such as cephalosporins, penicillins or sulfonamides,
are more likely to cause a serum sickness-like syndrome with
fever, arthralgias and rash in addition to lymphadenopathy.
Pendekatan diagnosis

Pemeriksaan fisik
Karakter
1-2,25dan
cmukuran kelenjar getah bening
: keganasan : 8%
di
213atas
penderita dewasa , dengan ukuran
2,25 cm : keganasan : 38 %
kelenjar :
di bawah 1 cm : tidak ada keganasan
Pendekatan diagnosis

Pemeriksaan fisik
Karakter dan ukuran kelenjar getah
bening :
ukuran kelenjar maksimum 2 cm dan 1,5
cm merupakan batas ukuran yang
memerlukan evaluasi lebih lanjut untuk
menentukan adanya keganasan dan
penyakit granulomatous

Ferrer R. Am Fam Physician 1998;58:1315


Bazemore AW. Physician 2002;66:2103-10
Physical Examination
Size.
Pain/Tenderness :The presence or absence of tenderness does not reliably
differentiate benign from malignant nodes.
Consistency: Stony-hard nodes are typically a sign of cancer, usually
metastatic. Very firm, rubbery nodes suggest lymphoma. Softer nodes are
the result of infections or inflammatory conditions. Suppurant nodes may
be fluctuant. The term "shotty" refers to small nodes that feel like
buckshot under the skin, as found in the cervical nodes of children with
viral illnesses.
Physical Examination
Matting : can be either benign (e.g.,
tuberculosis, sarcoidosis) or malignant (e.g.,
metastatic carcinoma or lymphomas
Location : infectious mononucleosis causes
cervical adenopathy and a number of sexually
transmitted diseases are associated with
inguinal adenopathy
Pemeriksaan fisik

Pemeriksaan fisik
Lokasi limfadenopati :
Limfadenopati daerah kepala dan
leher
Limfadenopati epitrohlear
limfadenopati aksila
Limfadenopati supraklavikula
Limfadenopati inguinal
Limfadenopati generalisata
Physical Examination
Supraclavicular lymphadenopathy has the highest risk of malignancy,
estimated as 90 percent in patients older than 40 years and 25 percent in
those younger than age.
Lymphadenopathy of the right supraclavicular node is associated with
cancer in the mediastinum, lungs or esophagus.
The left supraclavicular (Virchow's) node receives lymphatic flow from the
thorax and abdomen, and may signal pathology in the testis, ovaries,
kidneys, pancreas, prostate, stomach or gallbladder. Although rarely
present
Algoritme evaluasi limfadenopati

Anamnesa, pemeriksaan fisik


Jinak, self Autoimun/ keganasan Tidak
limited infeksi diketahui

Bazemore AW. Physician 2002;66:2103-10


Algoritme evaluasi limfadenopati

Jinak, self limited Autoimun/ infeksi

Dapat diterapi ? positif Tes spesifik

ya negatif
tidak

Reassurance,
Terapi penjelasan Penyebab
perjalanan tidak
diketahui
Pemantauan penyakit Bazemore AW. Physician 2002;66:2103-10
Algoritme evaluasi limfadenopati
Sugestif Tidak diketahui SHAK ?
keganasan
Risiko
tinggi Risiko keganasan

Pemeriksaan
sesuai indikasi
Risiko rendah
generalisata regional
Biopsi eksisi

Test hematologi, Observasi


PPD, HIV, 1 bulan
negatif positif HbsAg, ANA
negatif
menghilang
menetap

biopsi
diketahui negatif Pemantauan
Evaluation of Suggestive S & S Associated with Lymphadenopathy

Mononucleosis-type Fatigue, malaise, fever, atypical


syndromes lymphocytosis
Epstein-Barr virus* Splenomegaly in 50% of patients Monospot, IgM EA or VCA
Toxoplasmosis* 80 to 90% of patients are IgM toxoplasma antibody
asymptomatic
Cytomegalovirus* Often mild symptoms; patients may IgM CMV antibody, viral
have hepatitis culture of urine or blood
Initial stages of HIV "Flu-like" illness, rash HIV antibody
infection*
Cat-scratch disease Fever in one third of patients; cervical Usually clinical criteria; biopsy
or axillary nodes if necessary
Pharyngitis due to group A Fever, pharyngeal exudates, cervical Throat culture on appropriate
streptococcus, nodes medium
gonococcus
Tuberculosis lymphadenitis* Painless, matted cervical nodes PPD, biopsy
Secondary syphilis* Rash RPR
Hepatitis B* Fever, nausea, vomiting, icterus Liver function tests, HBsAg
Lymphogranuloma venereum Tender, matted inguinal nodes Serology

Chancroid Painful ulcer, painful inguinal nodes Clinical criteria, culture

Lupus erythematosus* Arthritis, rash, serositis, renal, neurologic, hematologic Clinical criteria, antinuclear antibodies,
disorders complement levels

Rheumatoid arthritis* Arthritis Clinical criteria, rheumatoid factor

Lymphoma* Fever, night sweats, weight loss in 20 to 30% of patients Biopsy

Leukemia* Blood dyscrasias, bruising Blood smear, bone marrow

Serum sickness* Fever, malaise, arthralgia, urticaria; exposure to antisera Clinical criteria, complement assays
or medications

Sarcoidosis Hilar nodes, skin lesions, dyspnea Biopsy

Kawasaki disease* Fever, conjunctivitis, rash, mucous membrane lesions Clinical criteria
Less common causes of lymphadenopathy

Lyme disease* Rash, arthritis IgM serology

Measles* Fever, conjunctivitis, rash, cough Clinical criteria, serology

Rubella* Rash Clinical criteria, serology

Tularemiala* Fever, ulcer at inoculation site Blood culture, serology

Brucellosis* Fever, sweats, malaise Blood culture, serology

Plague Febrile, acutely ill with cluster of tender nodes Blood culture, serology

Typhoid fever* Fever, chills, headache, abdominal complaints Blood culture, serology

Still's disease* Fever, rash, arthritis Clinical criteria, antinuclear antibody,


rheumatoid factor

Dermatomyositis* Proximal weakness, skin changes Muscle enzymes, EMG, muscle biopsy

Amyloidosis* Fatigue, weight loss Biopsy

*--Causes of generalized lymphadenopathy.


EA=early antibody; VCA=viral capsid antigen; CMV=cytomegalovirus; HIV=human immunodeficiency virus; PPD=purified protein derivative; RPR=rapid plasma reagin; HBsAg=hepatitis B
surface antigen; EMG=electromyelography.
Unexplained Lymphadenopathy
Generalized Lymphadenopathy
almost always indicates a systemic disease is present,
proceed with specific testing as indicated.
If a diagnosis cannot be made, the clinician should obtain a
biopsy of the node.
The diagnostic yield of the biopsy can be maximized by
obtaining an excisional biopsy of the largest and most
abnormal node
The physician should not select inguinal and axillary nodes for
biopsy, since they frequently show only reactive hyperplasia
Unexplained Lymphadenopathy
Localized Lymphadenopathy

The decision about when to biopsy is more difficult.


Patents with a benign clinical history, an unremarkable physical
examinaton and no consttutonal symptoms should be reexamined in
three to four weeks to see if the lymph nodes have regressed or
disappeared.
Patents with unexplained localized lymphadenopathy who have
consttutonal symptoms or signs, risk factors for malignancy or
lymphadenopathy that persists for three to four weeks should undergo a
biopsy.
Unexplained Lymphadenopathy
Localized Lymphadenopathy
Biopsy should be avoided in patents with
probable viral illness because lymph node
pathology in these patents may sometmes
simulate lymphoma and lead to a false-
positve diagnosis of malignancy.
Take home message
Limfadenopati merupakan
pembesaran kelenjar getah bening
dengan ukuran lebih besar dari 1 cm
Etiologi : MIAMI :
malignant

infectious
autoimmune

miscellaneous/unusual
iatrogenic
Take home message

Lokasi Karakteristik
Usia
kelenjar kelenjar

Lamanya
limfadenopati Gejala lain

Etiologi
limfadenopati
Take home message
Lokasi kelenjar getah bening leher
dapat dibagi dalam 6 level untuk
memperkirakan sumber keganasan
primer yang bermetastase
Level 1 : submental dan
submandibular
Level 2 : upper jugular
Level 3 : middle jugular
Level 4 : lower jugular
Level 5 : posterior triangle group
Level 6 : anterior triangle group
Take home message

Biopsi eksisi merupakan prosedur


diagnostik terpilih bila didapatkan
kecurigaan adanya keganasan.

You might also like