5th Plenary
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.
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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
• 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
Lupus erythematosus* Arthritis, rash, serositis, renal, neurologic, hematologic Clinical criteria, antinuclear antibodies,
disorders complement levels
Serum sickness* Fever, malaise, arthralgia, urticaria; exposure to antisera Clinical criteria, complement assays
or medications
Kawasaki disease* Fever, conjunctivitis, rash, mucous membrane lesions Clinical criteria
Less common causes of lymphadenopathy
Plague Febrile, acutely ill with cluster of tender nodes Blood culture, serology
Typhoid fever* Fever, chills, headache, abdominal complaints Blood culture, serology
Dermatomyositis* Proximal weakness, skin changes Muscle enzymes, EMG, muscle biopsy
- 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.
B. Cause by a mallignancy