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Pendekatan

Diagnostik
Limfadenopati :
pendekatan diagnostik

Limfadenopati
dan 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
Limfadenopati
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;66:210310
Limfadenitis
Radang pada kelenjar getah bening yang

Klasifikasi
Limfadenopati
lokalisata

Limfadenopati
pada 1 regio

Limfadenopati
generalisata

limfadenopati
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
Silicosis

Histiositosis
Hipertrigliseridemia

Storage disease

Bazemore AW. Physician 2002;66:2103-10

Etiologi : Iatrogenic

Alopurinol

Pirimidone

Atenolol

Pirimetamine

SerumCaptopril
sickness
Obat obatan
:
Carbamazepine
Hydralazine
Penisilin

Kuinidin
Trimetoprim sulfametoksazole
Sulindac
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
dan
getah bening
1-2,25
cmukuran kelenjar
: 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
limited
infeksi

Tidak
diketahui

Bazemore AW. Physician 2002;66:2103-10

Algoritme evaluasi limfadenopati


Jinak, self limited

Dapat diterapi ?
ya

tidak

Reassurance,
Terapi
penjelasan
perjalanan
Pemantauan penyakit

Autoimun/ infeksi

positif

Tes spesifik
negatif

Penyebab
tidak
diketahui
Bazemore AW. Physician 2002;66:2103-10

Algoritme evaluasi limfadenopati


Sugestif
keganasan

Tidak diketahui
Risiko
tinggi

Pemeriksaan
sesuai indikasi

SHAK ?

Risiko keganasan

Risiko rendah
generalisata
regional

Biopsi eksisi

negatif

positif

Test hematologi,
PPD, HIV,
HbsAg, ANA
negatif

Observasi
1 bulan
menghilang

menetap
diketahui

biopsi
negatif

Pemantauan

Evaluation of Suggestive S & S Associated with Lymphadenopathy

Mononucleosis-type
syndromes

Fatigue, malaise, fever, atypical


lymphocytosis

Epstein-Barr virus*

Splenomegaly in 50% of patients

Monospot, IgM EA or VCA

Toxoplasmosis*

80 to 90% of patients are


asymptomatic

IgM toxoplasma antibody

Cytomegalovirus*

Often mild symptoms; patients may


have hepatitis

IgM CMV antibody, viral


culture of urine or blood

Initial stages of HIV


infection*

"Flu-like" illness, rash

HIV antibody

Cat-scratch disease

Fever in one third of patients; cervical


or axillary nodes

Usually clinical criteria; biopsy


if necessary

Pharyngitis due to group A


streptococcus,
gonococcus

Fever, pharyngeal exudates, cervical


nodes

Throat culture on appropriate


medium

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


disorders

Clinical criteria, antinuclear antibodies,


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


or medications

Clinical criteria, complement assays

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.
Patients with a benign clinical history, an
unremarkable physical examination and no
constitutional symptoms should be reexamined in
three to four weeks to see if the lymph nodes have
regressed or disappeared.
Patients with unexplained localized
lymphadenopathy who have constitutional 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
patients with probable viral
illness because lymph node
pathology in these patients may
sometimes simulate lymphoma
and lead to a false-positive
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


Usia

Lokasi
kelenjar

Lamanya
limfadenopati

Karakteristik
kelenjar

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.