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1 : Lymphatic System Dr. Dikesh Patel
2 : Introduction Components Lymph is the fluid Vessels – lymphatics Structures & organs Functions Return tissue fluid to the bloodstream Transport fats from the digestive tract to the bloodstream Surveillance & defense
3 : Lymphatics Originate as lymph capillaries Capillaries unite to form larger vessels Resemble veins in structure Connect to lymph nodes at various intervals Lymphatics ultimately deliver lymph into 2 main channels Right lymphatic duct Drains right side of head & neck, right arm, right thorax Empties into the right subclavian vein Thoracic duct Drains the rest of the body Empties into the left subclavian vein
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6 : Lymphatic vessels join to form lymphatic trunks. Lymphatic trunks join to form : Thoracic duct (3/4 of body) Right lymphatic duct (drains right arm, and right side of head, neck and upper torso) These empty into subclavian veins at junction with internal jugular vein.
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9 : Lymphatic capillaries Made of a single layer of squamous epithelial cells Slightly larger than blood capillaries Cells overlap and act as one-way valves Opened by pressure of interstitial fluid Anchoring filaments attach cells to surrounding tissue
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12 : Lymphatic vessels Resemble veins (same 3 layers) Found throughout body except: Avascular tissues Central nervous system Splenic pulp Bone marrow
13 : Lymph Tissue 3 types Diffuse lymphatic tissue No capsule present Found in connective tissue of almost all organs Lymphatic nodules No capsule present Oval-shaped masses Found singly or in clusters Lymphatic organs Capsule present Lymph nodes, spleen, thymus gland
14 : Function of the Lymphatic System Defense against harmful organisms and chemicals 2 types of defense Nonspecific Specific Specific defense = immunity Humoral immunity involves B cells that become plasma cells which produce antibodies that bind with specific antigens. Cell-mediated immunity involves T cells that directly destroy foreign cells
15 : CNS-modified lymphatic function No true lymphatic vessels in CNS Perivascular spaces contain CSF & communicate with subarachnoid space Plasma filtrate & escaped substances in perivascular spaces returned to the vascular system in the CSF via the arachnoid villi which empties into dural venous sinuses Acts a functional lymphatic system in CNS
16 : Lymphatic Organs Red bone marrow Primary organs Thymus gland Lymph nodes Lymph nodules Secondary organs Spleen
17 : Tonsils Multiple groups of large lymphatic nodules Location – mucous membrane of the oral and pharyngeal cavities Palatine tonsils Posterior-lateral walls of the oropharynx Pharyngeal tonsil Posterior wall of nasopharynx Lingual tonsils Base of tongue
18 : Tonsils
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20 : Spleen Largest lymphatic organ Located between the stomach & diaphragm Structure is similar to a node Capsule present But no afferent vessels or sinuses Histology Red pulp contains all the components of circulating blood White pulp is similar to lymphatic nodules Functions Filters blood Stores blood
21 : Spleen
22 : Thymus Gland Location – behind the sternum in the mediastinum The capsule divides it into 2 lobes Development Infant – conspicuous Puberty – maximum size Maturity – decreases in size Function Differentiation and maturation of T cells
23 : Thymus Gland
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28 : Lymph nodules are also found singly or in groups throughout the mucous membranes of the respiratory, urinary, reproductive and digestive tracts. MALT – mucosa associated lymphoid tissue Peyer’s patches in ileum Tonsils Some in appendix
29 : Definition: Lymphadenopathy Lymph nodes that are abnormal in size, consistency or number Generalized Localized
30 : Peripheral lymphadenopathy Most cases benign, self limited illness Primary or secondary manifestation of 100 illnesses The CHALLENGE is to decide if it is representative of a serious illness…
31 : Lymph node character Size Site Consistency Pain with palpation
32 : Size Greater than one centimeter generally considered abnormal Exception inguinal area, lymph nodes commonly palpated (>1.5 cm) Size does not indicate a specific disease process Obese and thin population
33 : Pain….. Indication of rapid increase in size: stretch of capsular shell NOT useful in determining benign vs malignant state Inflammation, suppuration, hemorrhage
34 : Consistency Stone hard: typical of cancer usually metastatic Firm rubbery: can suggest lymphoma Soft: infection or inflammation Shotty “buckshot under skin” Suppurated nodes: fluctuant Detect node from stroma Matting
35 : Supraclavicular Nodes Drain the mediastinum and abdomen Breast, GI, Lung Malignancies Hodgkins/NHL Chronic Fungal and mycobacterial
36 : Axillary Nodes Drain arm, breast, thorax and neck Hodgkin, NHL Melanoma (drains back of arm) Staph/strep Cat scratch Silicone prosthesis
37 : Inguinal lymphadenopathy Drain the lower extremity, genitalia, buttocks, abdominal wall Normal People who walk barefoot Squamous cell carcinoma of penis or vulva Venereal disease
38 : Epitrochlear Lymphoma/CLL Mono Historically associated with syphilis, rubella, leprosy Studies to indicate an association with early HIV disease in sub-Saharan Africa, areas with high prevalence of disease
39 : Hilar, mediastinal, abdominal >1 cm considered pathological Pneumonia/inflammatory process can cause unilateral hilar disease Lymphadenopathy limited to abdomen likely malignant
40 : Highest rate of malignancy Right Supraclavicular Mediastinum Lungs Upper 2/3 esophagus Left Supraclavicular Virchow node Testes/ovaries Kidneys Pancreas Prostate Stomach Lower Esophagus
41 : Famous nodes Virchows Left supraclavicular (abdominal or thoracic ca) Sister Joseph Para-umbilical (gastric adenoca) Delphian node Prelaryngeal (thyroid or laryngeal ca) Node of Cloquet (Rosenmuller node) Deep inguinal near femoral canal
42 : Presentation of lymphadenopathy Unexplained lymphadenopathy 3/4 presents with localized 1/4 present with generalized
43 : Differential Diagnosis CHICAGO
44 : ChicagoCancer Heme malignancies: Hodgkins, NHL, acute and chronic leukemias, waldenstroms, multiple myeloma (plastmocytomas) Metastatic: solid tumor breast, lung, renal, cell ovarian
45 : cHicagoHypersensitivity syndromes Serum sickness Serum sickness like illness Drugs Silicone Vaccination Graft vs Host
46 : Specific Medications Cephalosporins Atenolol Captopril Dilantin Sulfonamides Carbamazepine Primodine Gold Allupurinol
47 : ChicagoInfections Viral Bacterial Protozoan Mycotic Rickettsial (typhus) Helminthic (filariasis)
48 : VIRAL EBV…mono spot test CMV….cmv titers, immunsuppresed, transplant recipient, recent blood transfusion HIV…IV drug use, high risk sexual behavior Hepatitis….IV drug use Herpes Zoster….superficial cutaneous nodules
49 : Bacterial Staph/strep: cutaneous source, lymphadenitis Cat scratch: bartonella hensalae, two weeks after inoculation Mycobacterium: TB and non-tb, host characteristics (HIV, foreign born, low socioeconomic status, homeless)
50 : Spirochete Syphilis: Treponema pallidum Primary localized inguinal lymph nodes and secondary, non-treponemal, treponemal Lyme disease
51 : Protozoan Toxoplasmosis: ELISA assay, intracellular protozoan toxoplasmosis gondii….bilateral, symmetrical, non-tender cervical adenopathy …consider undercooked meat, reactivation in immuncompromised host
52 : chicagoConnective Tissue Disease Rheumatoid Arthritis SLE Dermatomyositis Mixed connective tissue disease Sjogren
53 : chicagoAtypical lymphoproliferative disorders Castleman’s disease Wegeners Angioimmuonplastic lymphadenopathy with dysproteinemia
54 : chicaGoGranulomatous Histoplasmosis Mycobacterial infections Cryptococcus Silicosis: coal, foundry, ceramics, glass Berylliosis: metal, alloys Cat Scratch
55 : OTHER…….chicago Kawasaki Transformation of germinal centers
56 : Unexplained Generalized lymphadenopathy Always requires an evaluation Start with CXR and CBC Review Medications PPD, RPR, Hepatitis screen, ANA, HIV No yield on above test: Biopsy most abnormal node
57 : BIOPSY Can be done by bedside, open surgery, mediastinocopy or by needle aspiration* FNA not recommended cannot distinguish between lymphomas (nodal architecture needs to be intact) FNA reserved for established diagnosis and to demonstrate recurrence
58 : Diagnostic Yield Ideally axillary and inguinal nodes are avoided as often demonstrate reactive hyperplasia Preferred supraclavicular, cervical, axillary, epitrochlear, inguinal Complications include vascular and nerve injury


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