5th Plenary

25 D
1. Yudha Bagus Sajiwo
2. Ulfa Rahmi
3. Mai Ismil Husni Tasyriqiyyah
4. Eriza Amalia Zain
5. Rida Khairunisa F
6. Katelino Marpaung
7. Reforma Setiana
8. Laras Surakusuma
 Limfadenopati
Benjolan di Leher Pak Deno
Pak Deno 36 th seorang sopir datang berobat ke puskesmas dengan
keluhan adanya benjolan pada lehernya yang telah dirasakan
sejak satu bulan ini. Awalnya benjolan hanya terdapat pada leher
bagian kiri, namun saat ini bertambah hingga leher kanan. Selain
itu juga mengeluhkan adanya penurunan nafsu makan ,
penurunan BB, batuk-batuk serta demam disertai keringat dingin
sejak 3 bulan yang lalu. Dari hasil pemeriksaan dokter
didapatkan adanya limfadenopati dengan ukuran rata-rata
sebesar kelereng ,konsistensi kenyal seperti karet,dan tidak
didapatkan adanya nyeri tekan. Dari hasil pemeriksaan lainnya
didapatkan hepatosplenomegali dan paru dalam batas normal.
Hasil pemeriksaan laboratorium didapatkan, Hb :
8.7 g/dL,leukosit 5500/mm3, hitung jenis:
0/5/6/73/8/8, trombosit 156.000/mm3, LED
105 mm/1 jam. Dari semua pemeriksaan
tersebut dokter menerangkan bahwa masih
terdapat beberappa kemungkinan penyebab
terjadinya benjolan pada leher pak Deno dan
menganjurkan agar pak Deno dirujuk ke RS
untuk dilakukan pemeriksaan biopsi kelenjar
dan rontgen thorax .
Bagaimana anda menjelaskan apa yang terjadi
pada Pak Deno ?
 I. Terminology
1. Limfadenopati
Pembengkakan yang terjadi pada kelenjar
getah bening akibat respon dari suatu
penyakit
2. Biopsi Kelenjar
Pengambilan jaringan pada kelenjar untuk
dilakukan pemeriksaan pada kelenjar tersebut
 II. Problem’s Identification
1. Mengapa ada benjolan pada leher Pak Deno?
2. Mengapa pasien mengeluhkan BB menurun,
demam keringat dingin ,serta batuk-batuk
pada sejak 3 bulan lalu ?
3. Mengapa benjolan pada leher pak deno
bertambah hingga leher kanan ?
4. Apa interpretasi dari hasil pemeriksaan fisik
pak Deno ?
5. Apa interpretasi hasil lab ?
6. Mengapa dilakukan biopsi kelenjar dan
rontgen thorax ?
7. Bagaimana pendekatan diagnosis
limfadenopati?
8. Bagaimana tata laksana untuk pak Deno?
9. Bagaimana prognosis pak Deno ?
 III. Hypothesis
1. Kemungkinan bengkak pada leher pad Deno
disebabkan oleh beberapa penyebab seperti :
- Pembesaran kelenjar tiroid
- Pembengkakan pada kelenjar limfe yang
bisa disebabka oleh berbagai hal seperti
infeksi atau keganasan , contohnya tonsilitis ,
limfoma malignum
- Kista
-Skin Taq
2.- Hepatosplenomegali-cepat kenyang-nafsu makan
menurun-metabolisme menurun-ATP menurun-
BB menurun . Disisi lain, jika limfadenopati pak
Deno karena keganasan – ATP yang dihasilkan
untuk proliferasi abnormal sel-sel kanker
sehingga untuk tubuh berkurang-BB menurun .
- Batuk-batuk , kalau keganasan kmngkinan
berarti sudah metastasis ke paru
- Demam keringat dingin – Perubahan set point di
hipotalamus – penigkatan IL 1 – hormon leptin
tepengaruhi di jaringan adiposa- nafsu makan
menrun
3. Kalau keganasan berarti sel kanker sudah
metastasis ke kelenjar limfe terdekatnya
mengikuti aliran pembuluh limfe (Lokalisata) .
4. Limfadenopati sebesar kelereng dengan
konsistensi kenyal seperti karet kemungkinan
keganasan dari kelenjar limfe itu sendiri,yaitu
limfoma. Dengan ukuran sebesar kelereng
limfadenopatinya lokalisata berarti
kemungkinan hodgkin. Hepatosplenomegali
karena metastasisnya .
5. - Hb 8.7 gr/dL – Anemi
- Leukosit 5500/mm3 – Normal
- 0 – basofil- normal
5 – eosinofil - meningkat
6 – NB - Normal
73- NS - Menignkat
8 – Limfosit - Menurun
8 – Monosit – Batas normal
- Trombosit – Normal
- LED – Mneigkat karena anemi
6. Untuk memastikan diagnosis .
7. Anamnesis – Gejala anemi , bb menurun, demam
keringat dingin , nafsu makan menurun
Pemeriksaan fisik – hepatosplenomegali ,
limfadenopati (ukuran konsistensi jumlah nyeri
tekan )
Pem penunjang - lab , rontgen , biopsi
8. Radioterapi
Kemoterapi
Pengangkatan kelenjar
9. Progonsis tergantung level keganasan
IV. SCHEME
 Limfadenopati
Diagnosis

Etiopatogene
Neoplasma Non Neoplasma
sis

Anamnesis
Primer Sekunder Infeksi , Autoimun,
Iotrogenik
Pem Fisik
Tatalaksana
Radioterapi ,
kemoterapi , obat- Antibiotik dll Pem Penunjang
obatan

Prognosis
 V. Learning Objectives
1. To explain Etiopathogenesis of Limfadenopathy
2. To Explain Classification of Limfadenopathy
3. To Explain Clinical Symptom of
Limfadenophathy
4. To Explain Physical Examination of
Limfadenophathy
5. To explain treatment of Limfadenophathy
6. To Explain Supporting examination of
limfadenophathy
7. To Explain the Limfadenophathy’s Prognosis
 1. Lymphadenopathy
• Lymph node that abnormal in size , consistency, or number
• The body has approximately 600 lymph nodes, but only those
in the submandibular, axillary or inguinal regions may
normally be palpable in healthy
• 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.

15
 Pathology

• Infections
• Reactive hyperplasias
• Sarcoidosis
• Metastatic tumors
• Malignant lymphomas
– Non-Hodgkin’s lymphoma-NHL
– Hodgkin’s lymphoma
 Pathology
• Infections
– Bacterial
• Acute inflammation, abscess formation
– Granulomatous, caseous and noncaseous
– Diagnosis by culture, serologies, and/or
special stains
Lymph vessels will flow to the KGB so that from
the KGB location will be known flow of
lymph vessels that pass through it. Because it
is passed by the flow of lymph vessels that can
carry the antigen (microbes, foreign
substances) and have the body's defense cells
so if there is an antigen that infects the lymph
nodes can produce more body defense cells to
overcome the antigen so that the sap gland
enlarged.
Enlarged lymph nodes can be derived from the
addition of body defense cells derived from the
KBG itself such as lymphocytes, plasma cells,
monocytes and histiocytes or due to the arrival of
inflammatory cells (neutrophils) to overcome
infections in the lymph nodes (lymphadenitis),
infiltration (inclusion) of malignant cells or heaps
of metabolite macrophage disease (gaucher
disease). By knowing the location of KGB
enlargement then we can direct to the location of
the possibility of infection or cause of KGB
enlargement. Bumps
2. lymphadenopathy
Classification
80 % caused by infectious disease
20 % caused by neoplasm

20% neoplasm : 80 % secondary cancer , 20 %

primary cancer
 Classification
• By extent
• By malignancy
• By localization
 By extent
• Localized lymphadenopathy : due to
localized spot of infection e.g., an infected spot
on the scalp will cause lymph nodes in the
neck on that same side to swell up

• Generalized lymphadenopathy: due to a

systemic infection of the body e.g., influenza
or secondary syphilis
 By malignancy

Benign lymphadenopathy is distinguished from

malignant causes which mainly refer to
lymphomas or lymph node metastasis
 By localization
• Mediastinal lymphadenopathy : an
enlargement of the Mediastinal lymph nodes
• Bilateral hilar lymphadenopathy
: is a bilateral enlargement of the lymph nodes of
pulmonary hila. It is a radiographic term that
describes the enlargement of mediastinal lymph
nodes and is most commonly identified by a
chest x-ray.
3. Clinical Symptom of
Limpfadenophathy
 Caused by an infection

• Fever
• Limfadenophathy
• Soft and tender
• Warm and rubor
 Caused by a lymfoma
• Wight loss
• Limfadenphathy without a tender
• Hard consistency
• Fever
• Night sweating
4. Physical Examination
 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
 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 testes, ovaries, kidneys,
pancreas, prostate, stomach or gallbladder. Although
rarely present
Evaluation of Suggestive S & S Associated with Lymphadenopathy
Mononucleosis-type
syndromes
Epstein-Barr virus*
Toxoplasmosis*
Cytomegalovirus*
Initial stages of HIV
infection*
Cat-scratch disease
Pharyngitis due to group A
streptococcus,
gonococcus
Tuberculosis lymphadenitis*
Secondary syphilis*
Hepatitis B*
Fatigue, malaise, fever, atypical
lymphocytosis
Splenomegaly in 50% of patients
80 to 90% of patients are
asymptomatic
Often mild symptoms; patients may
have hepatitis
"Flu-like" illness, rash
Fever in one third of patients; cervical
or axillary nodes
Fever, pharyngeal exudates, cervical
nodes
Painless, matted cervical nodes
Rash
Fever, nausea, vomiting, icterus
Monospot, IgM EA or VCA
IgM toxoplasma antibody
IgM CMV antibody, viral
culture of urine or blood
HIV antibody
Usually clinical criteria; biopsy
if necessary
Throat culture on appropriate
medium
PPD, biopsy
RPR
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
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.
5. TREATMENT
 Treat the cause of Lymphadenopathy

- Because Of Infection

- Because Of Malignancy
6. Laboratory Examination of
Lymphadenopathy
 Neoplasm
• FNAB
• bone marrow aspiration (BMP) and bone
marrow biopsy from two sides of spina illiaca
with a 2 cm long specimen
• Radiology
routine: PA and lateral photo thorax
specific: CT thoracic scan, abdominal
ultrasound, lymphography, lymphointigraphy
• Histopatology
• Histokimia
• Immunohostokimia n Immunophenotyping:
paraffin panel
(CD 20,CD 3)
 non Neoplasm
• CBC (Complete Blood Count)/routine
hematology
• Radiology
• Throat culture
• Serology (antigen- antibody reaction)
• PPD(Purified Protein Derivative), test mantoux
for the diagnosis of TB in children
 Prognosis
A. Cause by an infection
- The prognosis for recovery is good if treated
promptly with antibiotics. In most cases, the
infection can be controlled in three or four days.
However, in some cases it may take several
weeks or months for the swelling to disappear,
the length of recovery depends on the cause of
the infection. Patients with untreated
lymphadenitis can develop abscesses, cellulitis,
or blood poisoning (septicemia), which is
sometimes fatal.
A. Cause by a mallignancy