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Peripheral Lymphadenopathy as a Primary Presenting Sign: A Study of 324 Cases from Asir Region

1992; King Faisal Specialist Hospital and Research Centre; Volume: 12; Issue: 1 Linguagem: Inglês

10.5144/0256-4947.1992.72

0975-4466

Nader Morad, Tarek Malatani, Abdur Rauf Khan, Nazir K. Hussain,

Mycobacterium research and diagnosis

Original ArticlesPeripheral Lymphadenopathy as a Primary Presenting Sign: A Study of 324 Cases from Asir Region Nader Morad, FCAP Tarek Malatani, FRCS(C) Abdur Rauf Khan, and FCAP Nazir HussainFCAP Nader Morad Address reprint requests and correspondence to Dr. Morad: Department of Pathology, College of Medicine, King Saud University, P.O. Box 641, Abha, Saudi Arabia. From the Departments of Pathology, Asir Central Hospital, Abha. Search for more papers by this author , Tarek Malatani From the Department of Surgery, Asir Central Hospital, Abha. Search for more papers by this author , Abdur Rauf Khan From the Departments of Pathology, Asir Central Hospital, Abha. Search for more papers by this author , and Nazir Hussain From the College of Medicine, King Saud University, and Department of Pathology, Asir Central Hospital, Abha. Search for more papers by this author Published Online:1 Jan 1992https://doi.org/10.5144/0256-4947.1992.72SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutABSTRACTABSTRACTSuperficial lymph node biopsies received over a four year-period, 1987 to 1990, at the histopathology laboratory of Asir Central Hospital were reviewed. Total number of patients was 324, all presented with peripheral lymphadenopathy as the primary sign. Two hundred sixty-six patients (82%) were Saudi nationals and 58 patients (18%) were non-Saudi nationals living in Asir region. Granulomatous lymphadenitis was the most common pattern (43%), followed by: nonspecific lymphoid hyperplasia (33%), malignant lymphoma (13%), metastatic nonlymphoid malignant neoplasm (6.6%), and miscellaneous specific lymphadenopathies (4.4%). The distribution patterns of various histopathologic findings according to age, sex, nationality and lymph node location are included.IntroductionEnlargement of superficial lymph nodes or peripheral lymphadenopathy is a common medical problem. In many instances a definitive diagnosis is not possible on the basis of clinical and laboratory findings. In such cases histopathologic examination of excisional lymph node biopsies is essential to establish a final diagnosis.Several histopathologic patterns are readily recognized in lymph node biopsies [1]. Enlargement of a lymph node due to expansion of lymphoid follicles or interfollicular zone by a benign lympho-histiocytic cellular infiltrate is a nonspecific finding designated “reactive lymphoid hyperplasia.” The latter change could be induced by systemic or local infections, drug reaction, immune-mediated disorders and others. However, several other specific histopathologic patterns can settle a definitive diagnosis in a particular case. These include the presence of granulomatous reaction, infiltration of the lymph node by malignant lymphoid or nonlymphoid cells as well as several other patterns including toxoplasmic lymphadenitis, cat scratch disease, Kikuchi's necrotizing lymphadenitis, dermatopathic lymphadenopathy, angioimmunoblastic lymphadenopathy and others.Many reports summarizing the distribution patterns of various causes of lymphadenopathy among populations of various regions of the world including western countries [2–5], the Middle East [6], and the Kingdom of Saudi Arabia [7–10] are present in the medical literature.The significance of these studies is not only to identify common health problems in a particular region but also to identify populations at high risk of developing a particular disease process. To our knowledge, the current study is the first to reportthe pattern of peripheral lymphadenopathy in this region of the Kingdom. Comparison of our findings with those reported from other provinces of Saudi Arabia are included.MATERIAL and METHODSThe pathology reports of 324 consecutive superficial lymph node biopsies received at Asir Central Hospital laboratory over a four year period, 1987 to 1990, were reviewed. Only patients presenting with peripheral lymphadenopathy were included. Lymph nodes obtained as a part of radical cancer resection were excluded. Only one biopsy per patient was included even though the patient might have had more than one biopsy. Patients' charts were reviewed only when the data on histopathology request forms were insufficient. The excisional lymph node biopsies were taken from patients seen at Asir Central Hospital as well as from general hospitals located in Khamis Mushait, Bisha, Zahran Al-Janoub, Sarat Abidah, Ahad Rufidah, Rijal Alma and Muhayl.All biopsies were fixed in 10% formalin and routine hematoxylin-eosin stained sections were examined. Ziehl-Neelsen and methenamine silver stains were done in cases showing granulomatous reactions. The results were tabulated and presented as percentage (crude relative) frequencies. The mean age of the cases studied was 31 ± 20 years (SD). The male to female ratio was 1:1.RESULTSThe distribution pattern of various histopathologic findings in 324 consecutive superficial lymph node biopsies are shown in Table 1. Granulomatous lymphadenitis presented the most common pattern (43%) with similar distribution among Saudi and non-Saudi nationals. The majority of the cases showed caseating granulomatous pattern (137) where noncaseating granuloma were seen in only three biopsies. Ziehl-Neelsen stain identified mycobacteria in eight cases of granulomatous reaction (6%). Stains for fungi were negative in all cases of ganulomatous lymphadenitis. Nonspecific reactive lymphoid hyperplasia and inflammation were identified in 106 biopsies (33%). Malignant lymphoma was identified in 43 cases (13%) including 30 cases of non-Hodgkin's lymphoma and 13 cases of Hodgkin's disease. Metastatic neoplasm was found in 21 biopsies (6.6%) and other specific patterns of lymphadenopathies were identified in 14 cases (4.4%). The latter included four cases of dermatopathic lymphadenopathy, three cases of toxoplasmic lymphadenitis, three cases of cat scratch disease, two cases of Kikuchi's necrotizing lymphadenitis, one case of histiocytosis X and one case of allergic granulomatosis.Table 1. Distribution of various histopathologic diagnoses among 324 patients with peripheral lymphadenopathy and in relation to nationality.Table 1. Distribution of various histopathologic diagnoses among 324 patients with peripheral lymphadenopathy and in relation to nationality.Females were more frequently affected by granulomatous lymphadenitis compared with males (89 female and 51 male patients). The mean age values and sex distribution of various histopathologic findings are shown in Table 2.Table 2. Age and sex distribution of324 patients with peripheral lymphadenopathy.Table 2. Age and sex distribution of324 patients with peripheral lymphadenopathy.Cervical lymph nodes were the most commonly biopsied group (65%). The overall diagnositc yield in 324 biopsies was 67% with supraclavicular lymph nodes giving the highest yield (80%) and the inguinal group giving the least diagnostic yield of 53% (Table 3).Table 3. Relative distribution of 324 biopsies according to location of lymph nodes and diagnostic yield* in each group.Table 3. Relative distribution of 324 biopsies according to location of lymph nodes and diagnostic yield* in each group.Table 4 shows the distribution patterns of various histopathologic diagnoses among different superficial lymph node groups. Cervical lymph nodes were the most commonly affected group by granulomatous reaction (68%), reactive hyperplasia (61%), lymphoma (72%), metastasis (57%), and other specific lymphadenopathies (65%).Table 4. Distribution of various histopathologic diagnoses according to lymph node location.Table 4. Distribution of various histopathologic diagnoses according to lymph node location.DISCUSSIONSeveral reports studying the pattern of lymphadenopathy in various provinces of the Kingdom have been reported during the last ten years [7–10]. The current study is the first to report the pattern of lymphadenopathy in Asir region located in the southern province of the Kingdom. In many aspects, our findings are similar to those of other reports. Granulomatous and reactive lymphadenopathy presented over 75% of the 324 cases included in this study. Other similar findings include the age distribution of various histopathologic patterns where granulomatous lymphadenitis, reactive hyperplasia and Hodgkin's disease tend to occur in younger age groups compared with non-Hodgkin's lymphoma and metastatic neoplasms. Also, in agreement with other reports, the cervical lymph nodes are the most common biopsied nodes and the general diagnostic yield of lymph node biopsy is 67% with the least yield obtained from biopsies of the inguinal groups (53%).In comparison to other reports from the Kingdom, the current study had shown peculiar findings in the pattern of lymphadenopathy, in the Asir region. In our study, the granulomatous lymphadenitis is more common in females compared with males (64% in females and 36% in males). Caseation is also very common in patients with granulomatous lymphadenitis in Asir region (98%) compared with 75% in other locations of the Kingdom [8]. Although a definitive diagnosis of tuberculous lymphadenitis cannot be made without the demonstration of mycobacteria by either microbiologie culture or special stains of the tissue sections, the high incidence of caseating granuloma makes tuberculosis the most likely cause of granulomatous lymphadenitis in our study. In support of this opinion is the fact that the majority of non-tuberculous granulomas are of the noncaseating type [1] which is uncommon among our cases.Hodgkin's disease presented only 30% of primary lymph node malignancy in our study when compared with 49% reported from other provinces [8]. The mixed cellularity type of Hodgkin's disease is the most common pattern in the current study (nine out of 13 cases), in agreement with findings from other areas of the Kingdom. Also of interest is the presence of two cases of Kikuchi's necrotizing lymphadenitis [11] among the relatively low number of biopsies included in our study compared with 1000 cases reported recently by Al-Sohaibani et al [8] where none of their biopsies showed the aforementioned diagnosis. Both cases were young Saudi females and one' of these two cases has been previously reported [12]. Whether this uncommon cause of lymphadenopathy is relatively common in this area has to await further information. This disease is of particular interest because the first patient reported in the medical literature with Kikuchi's lymphadenitis of internal lymph node groups was a young Saudi female [12].In this study we have demonstrated the pattern of lymphadenopathy among patients from the Asir region with emphasis on the points of similarity and dissimilarity between patients from this area of the Kingdom and other provinces. The underlying causes of the existing differences have to await further studies of environmental and other factors affecting people living in the Asir region.ARTICLE REFERENCES:1. Rosai J. Ackerman's surgical pathology, ed 7. St. Louis: CV Mosby, 1989;1269–1360. Google Scholar2. Anthony PP, Knowels SAS. "Lymphadenopathy as a primary presenting sign: a clinicopathologic study of 228 cases" . Br J Surg. 1983; 70:412–4. Google Scholar3. Doberneck RC. "The diagnostic yield of lymph node biopsy" . Arch Surg. 1983; 111:1203–5. Google Scholar4. Lake AM, Oskit TA. "Peripheral lymphadenopathy in childhood: 10-year experience with excisional biopsy" . Am J Dis Child. 1978; 132:357–9. Google Scholar5. Knight PJ, Mulne AF, Vassy LE. "When is lymph node biopsy indicated: children with enlarged peripheral nodes" . Pediatrics. 1982; 69:391–6. Google Scholar6. Amr SS, Kamal MF, Tarawneh MS. "The diagnostic value of lymph node biopsy" . J Surg Oncol. 1989; 42(4):239–43. Google Scholar7. 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Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byEl-Tayeb A and Raja M (2019) Hodgkin's Disease Presenting with Multiple Cervical Sinuses and Abscess Formation, Annals of Saudi Medicine , 19:4, (350-351), Online publication date: 1-Jul-1999.Malik G, Abolfotouh M, Jastania S, Morad N, Eltayeb E and Saydain G (2019) A Logistic Regression Model to Predict Nodal Malignancy among Cases With Lymphadenopathy, Annals of Saudi Medicine , 18:6, (518-521), Online publication date: 1-Nov-1998. Volume 12, Issue 1January 1992 Metrics History Accepted24 February 1991Published online1 January 1992 InformationCopyright © 1992, Annals of Saudi MedicinePDF download