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淋巴结病第一部分

(2009-05-22 22:46:13)
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Bookshelf » Clinical Methods » The Hematopoietic System » Lymphadenopathy

 

cm

Clinical Methods

WalkerH. Kenneth

HallW. Dallas

HurstJ. Willis

Butterworths0-409-90077-X1990

© 1990 Butterworth Publishers

MedicineHistoryPhysicalSymptomsSignsExamination

part

 Chapter 149:  Lymphadenopathy淋巴结病

Michael Karpf

A4456

Definition

Infrequently, patients will note enlarged lymph nodes and present with the chief complaint of having a nodule, a swollen gland, a "knot," or enlarged lymph nodes; more commonly, patients do not recognize that they have significantly enlarged lymph nodes, and the lymphadenopathy is discovered by the physician. Since lymphadenopathy can be associated with a wide range of disorders spanning relatively benign medical problems such as streptococcal pharyngitis to life-threatening diseases such as malignancies, the discovery of enlarged nodes represents an important physical finding that demands a systematic uation.

很少情况下病人会注意到增大的淋巴结,并诉说发现结节、肿胀的腺体、硬结或增大的淋巴结。通常情况下,病人并未注意到他们淋巴结显著增大,而是由内科医生发现。由于淋巴结病很多机体紊乱有关,可以是良性的疾病像链球菌性咽炎,也可是致命性疾病像恶性肿瘤,淋巴结肿大是体检很重要的发现并需要系统性评估。

Technique

In searching for lymph nodes, one must be gentle; otherwise, lymph nodes that are only minimally enlarged or embedded in tissue may not be apparent. Particular attention should be directed to the size, shape, and consistency of enlarged nodes. Lymph nodes that are smooth and relatively soft, but slightly enlarged, may be normal and reveal only hyperplasia when biopsied. Enlarged lymph nodes that have an irregular shape and a rubbery, hard consistency may be infiltrated by malignant cells. Tender nodes are suggestive of an inflammatory process. Matted nodes or nodes fixed to underlying structures should raise the question of malignancy or infection; freely movable nodes are more likely to occur in benign conditions.

淋巴结检查必须轻柔;否则,轻度肿大的淋巴结或在组织内的淋巴结不易被发现。要尤其注意肿大淋巴结的大小、形状和硬度。表面光滑、质地柔软的轻度肿大的淋巴结可能是正常的,活检仅提示增生。形状不规则、质地较韧、硬度较大的肿大的淋巴结可能有癌细胞浸润。柔软的结节多为炎症,融合的结节或固定的结节提示恶性肿瘤或感染,可活动的结节多发生在良性病变。

Figure 149.1 Lymph node locations in the neck. 颈部淋巴结

 

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Lymph node locations in the neck.

The extent and location of lymphadenopathy are important in determining and providing diagnostic clues to the cause of lymphadenopathy. All major lymph node chains should be uated in a systematic fashion. Begin with a visual inspection of the area, looking for asymmetry or erythema. Palpate in a systematic fashion, encompassing all accessible lymph nodes. For an examination of lymph nodes of the neck, the patient either sits or stands facing the examiner. The examiner's right hand explores the left side of the patient's neck and then the left hand of the examiner explores the right side of the patient's neck. Starting from the top of the neck and going down, all of the various cervical lymph node chains should be uated including the preauricular, posterior auricular, occipital, superior cervical, posterior cervical, submaxillary, submental, inferior deep cervical, and supraclavicular, as noted in

淋巴结病的范围和位置对诊断疾病来源非常重要。所有的淋巴结链应进行系统性的评估。对病变部位肉眼观察,看是否对称及有无红斑。系统性触诊,包括所有可触及的淋巴结。例如颈部淋巴结检查中,病人面向检查者坐着或站立。检查者的右手检查病人左侧淋巴结,左手检查右侧。沿颈部上部向下滑行,所有各样的颈部淋巴结都应检查到,包括耳前、耳后、枕部、颈上、颈后、下颌下、颌下、颈下和锁骨上,如图所示。

Figure 149.1.

 

In the absence of generalized adenopathy, enlargement of specific cervical lymph node groups can be helpful diagnostically. For example, posterior auricular adenopathy suggests rubella, whereas unilateral anterior auricular adenopathy is associated with lesions of the conjunctiva and eyelids with the resultant oculoglandular syndrome seen in trachoma, tularemia, cat-scratch fever, tuberculosis, syphilis, epidemic keratoconjunctivitis, and outbreaks of adenovirus type 3 pharyngoconjunctival fever. Oropharyngeal and dental infections can also cause cervical adenopathy. Bilateral cervical adenopathy is also prominent in tuberculosis, coccidioidomycosis, infectious mononucleosis, toxoplasmosis, sarcoid, lymphomas, and leukemias. However, a unilateral cervical mass that is firm and nontender should always raise the question of an undetected nasopharyngeal carcinoma.

在没有广义腺病的情况下,特殊颈部淋巴结组肿大对诊断很有帮助。例如,耳后腺病提示风疹,单侧耳前腺病和结膜、眼睑病变有关,像砂眼、野兔病(土拉菌病)、猫爪热(良性淋巴网状内皮细胞增生症)、结核、梅毒、流行性角结膜炎、爆发性腺病毒3致的咽结膜热导致的眼腺型。口咽炎及牙部感染同样导致颈部腺病。双侧颈部腺病在结核、球孢子菌病、传染性单核细胞增多症、弓形虫病、肉样瘤、淋巴瘤和白血病。单侧颈部肿块坚实不柔软要警惕潜在的鼻咽癌。

Supraclavicular adenopathy is almost always abnormal. When it is not part of generalized lymphadenopathy, it is suggestive of a primary malignancy in either the abdomen or the chest. Right-sided supraclavicular nodes drain parts of the lung and mediastinum and are signals of intrathoracic lesions, particularly in the lung and esophagus. Left-sided supraclavicular nodes, which carry the eponym "Virchow's nodes," are close to the thoracic duct and often signal intra-abdominal tumors, particularly from the stomach, ovaries, testes, or kidneys. Supraclavicular nodes are sometimes deep seated, and it is often helpful to have the patient perform a Valsalva maneuver in order to push the cupola of the lung upward, thereby bringing these deep-seated nodes to a more accessible position for palpation. If supraclavicular adenopathy is noted, the patient should also be closely examined for hilar and mediastinal adenopathy. Although a chest x-ray or computerized tomography is often needed to verify this type of lymphadenopathy, dullness to percussion over the manubrium is sometimes suggestive of an anterior mediastinal mass or mediastinal nodes.

锁骨上腺病通常不正常。若它不是广义的淋巴腺病的一部分,它提示原发恶性病变在腹腔或胸部。右侧锁骨上淋巴结引流肺部、纵隔淋巴液,是胸内病变尤其是肺和食管的信号。左侧淋巴结,被命名为“菲尔科结节”,靠近胸导管,是腹内肿瘤的病变,尤其是来自胃、卵巢、睾丸、肾等。锁骨上淋巴结有时位置较深,病人作咽鼓管充气以使肺顶向上,而使这些较深的淋巴结处在更易触摸的位置。如果锁骨上腺病非常显著,病人需仔细检查看有无肺门、纵隔腺病。尽管胸部x线或计算机断层扫描对区分淋巴腺病类型很有需要,胸骨柄叩诊浊音有时可提示前纵隔肿块或结节。

Figure 149.2 (A) Technique for palpation of axillary nodes. (B) (more...)

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(A) Technique for palpation of axillary nodes. (B) Technique for palpation of epitrochlear lymph nodes. (From judge RD, Zuidema GD, eds. Physical diagnosis: a physiologic approach. Boston: Little, Brown, 1963; 225.)

The patient should then be examined for axillary adenopathy. The patient may be either sitting or supine. The patient's arm, supported by one of the examiner's hands, should be held in a slightly flexed position and adducted. The examiner's right hand is used to examine the patient's left axilla, and the left hand for the right axilla, as shown in

需对病人腋下淋巴结检查。病人可坐位或仰卧位。检查者用手握着病人的手臂,使其轻度屈曲为并内旋。右手检查左腋下,左手检查右腋下,如图中示。

The examiner's fingers should be slightly cuffed and should reach as high into the apex of the axilla as possible. Fingers are brought down slowly, exerting gentle pressure against the thorax. This maneuver should be repeated several times in order to examine the lateral group, the medial group, and the pectoral group of axillary nodes. Axillary adenopathy may be part of a generalized process or may be localized and secondary to infection in the limb. Local infection or trauma causing the adenopathy should be searched for carefully. Concomitant epitrochlear, axillary, and supraclavicular adenopathy should raise the question of cat-scratch fever. In a female, unilateral axillary nodes raise the suspicion of an ipsilateral breast carcinoma.

检查者的手指并拢并尽可能触及腋尖。手指对胸壁施加一定的力度轻轻下滑。这个过程应多重复几次以充分检查腋窝淋巴结外侧组、中间组及胸部组。腋窝淋巴结肿大可能是全身性疾病的一部分表现,也可能是上肢局限性疾病或继发感染引起的。局限性感染或外伤引起的淋巴结肿大应仔细检查。同时有滑车上、腋窝、锁骨上淋巴结肿大者应考虑到猫爪热。在女性,单侧淋巴结肿大怀疑单侧乳腺癌。

Next, the patient should be uated for the possibility of epitrochlear nodes. Often, these nodes are overlooked, or inadequate techniques are employed to examine them. Epitrochlear nodes are best sought with the patient's elbow flexed to about 90°. The right epitrochlear area is approached by inserting the examiner's left hand from behind the patient's elbow while the examiner's right hand grasps the right wrist of the patient, supporting the forearm, as in

接下来,检查患者的滑车上淋巴结。常常,这些淋巴结被忽视或没有认真的被检查。检查滑车上淋巴结时,患者的肘部屈曲90度检查者的左手从患者肘后触摸右侧滑车上淋巴结同时右手握持患者的右腕,支撑前臂,如图。

Figure 149.2B. The fourth and fifth finger should fall just above the medial epicondyle of the humerus and then the other fingers will overlie the area where epitrochlear nodes are usually found. Examination of the left epitrochlear area is just the reverse of the right. Epitrochlear nodes are usually enlarged secondary to infections of the hand and forearm. Occasionally, neoplastic processes will present with isolated epitrochlear adenopathy. Enlarged epitrochlear nodes occur frequently in mononucleosis. In the past, epitrochlear lymphadenopathy was considered a diagnostically important sign of secondary syphilis, but now it is more commonly due to recurrent hand injury or infections in people who do manual labor.

第四、五手指落在肱骨内上髁上,其他手指停留在滑车上淋巴结易被发现的区域。左侧的检查和右侧相反。滑车上淋巴结肿大常继发于手部或前臂的感染。偶尔,肿瘤也会仅伴有孤立的滑车上淋巴结肿大。增大的滑车上淋巴结多发生在单核细胞增多症。过去,滑车上淋巴结肿大被认为继发性梅毒的具有诊断意义的体症;但是现在,它更多起见于体力劳动者复发性手损伤或感染。

Occasionally, lymph nodes can be found in the vicinity of the umbilicus. These nodes have the eponym "the node of Sister Mary Joseph" and are a signal of significant intra-abdominal lymphadenopathy, usually associated with malignant processes.

偶而,脐周淋巴结可触及。这些淋巴结命名为“约瑟夫玛丽姐妹淋巴结”,是腹内淋巴结肿大的表现,通常和恶性肿瘤有关。

The inguinal region should be carefully uated for significant lymphadenopathy. It is not uncommon for adults to have what has been termed "shotty" nodes in the inguinal region. These shotty nodes are usually firm, not fixed, and are less than a centimeter in diameter. They result from recurrent infections and insults to the feet and legs. Significantly enlarged and tender nodes in the inguinal region that are not part of generalized lymphadenopathy should suggest a variety of conditions including syphilis, chancroid, and lymphogranuloma venereum. Unilateral inguinal lymphadenopathy is usually a response to infection of an ipsilateral lower extremity. Inguinal adenopathy can also be part of systemic processes such as lymphoma or leukemia.

腹股沟区显著的淋巴结肿大要仔细评估。成人腹股沟区似弹丸样硬而圆的肿大淋巴结是不正常的。这些似弹丸样结节通常坚硬,不固定,直径小于1厘米。他们常起源于腿脚反复感染和受侵犯。显著增大且柔软的腹股沟区淋巴结若不是广泛淋巴结病的一部分应考虑其他很多情况像梅毒、软性下疳、性病淋巴肉芽肿。单侧腹股沟区淋巴结肿大常是单侧下肢感染的反应。腹股沟区淋巴结肿大也可是全身性疾病像淋巴瘤或白血病的一部分。

Femoral adenopathy is usually located in the femoral triangle in the area of the node of Cloquet. Although femoral adenopathy can also be secondary to chronic infection and trauma, it is much more commonly of pathologic significance than is inguinal adenopathy.

股淋巴结病常位于股三角的Cloquet淋巴结区。尽管股淋巴结病可继发于慢性感染或外伤,它比腹股沟淋巴结病更具病理学意义。

Occasionally lymphadenopathy can be found in the popliteal fossa. This adenopathy can be part of a generalized process or can be localized secondary to infection or trauma of the lower extremity.

偶尔腘窝区可见淋巴结病。这个淋巴结肿大可以是全身疾病的一部分,也局限于下肢继发感染或外伤。

Many important lymph node groups cannot be uated by the physical examination. Whenever there is evidence of generalized adenopathy, these groups should be uated carefully. Hilar and mediastinal adenopathy can compromise regional structures such as the superior vena cava or trachea and potentially cause a life-threatening complication.

很多重要的淋巴结组体检不能发现。任何存在广泛性淋巴结病的证据情况下,这些淋巴结组应被仔细评估。肺门和纵隔淋巴结可压迫区域组织像上腔静脉、支气管并可产生危及生命的并发症的可能性。

There are multiple lymph node groupings in the abdomen, including mesenteric, paraaortic, celiac, and retrogastric. Bulky abdominal adenopathy can also compromise structures, including the ureters and inferior vena cava, and can cause complications such as renal failure. Abdominal adenopathy is usually uated by computerized abdominal tomography, gallium scanning, ultrasonography, or lymphangiography.

腹腔里有多个淋巴结组,包括肠系膜淋巴结,腹主动脉旁淋巴结,腹腔干淋巴结,胃曲淋巴结。巨大的淋巴结可压迫结构像输尿管和下腔静脉,也可导致并发症像肾衰。腹腔淋巴结可通过腹腔计算机断层摄影术检查,镓扫描,超声检查或淋巴管造影术。

The spleen is part of the lymphatic system and should be carefully uated in any patient in whom other lymphadenopathy is present.

脾脏是淋巴系统的一部分,在任何有其他淋巴结病的病人中应认真检查。

Basic Science基础科学

There are over 500 lymph nodes gathered in a variety of groupings throughout the body. These nodes represent an integral part of both the immunologic and reticuloendothelial systems. Individual lymph nodes consist of lymphocytes clustered in lymphoid follicles and reticuloendothelial cells lining nodal sinuses. Each follicle contains a germinal center populated by rapidly proliferating B cells and macrophages. The germinal center is surrounded by densely packed small lymphocyte T cells that replicate at a slower rate. Both B and T cells function in the recognition of, and response to, antigenic stimulation. B cells are the principal effector cells of the humoral arm of the immune system, whereas T cells are the principal effector cells of the cellular arm of the immune system. Macrophages and cells of the reticuloendothelial system are also part of the immunologic system, but function in the phagocytosis of cellular debris or foreign substances such as viruses and bacteria that have gained access to the node from the area being drained. The reticuloendothelial system also clears some excess metabolites from the circulation.

有500个淋巴结在不同的族群分布全身。这些淋巴结是免疫系统和内皮系统主要部分。单个的淋巴结包括积聚在淋巴滤泡的淋巴细胞和沿淋巴窦分布的内皮细胞组成。每个滤泡含有一个大量快速增殖的B细胞和吞噬细胞的构成的生发中心。生发中心外周密布增殖低下的小淋巴T细胞。B细胞和T细胞可对对抗原刺激识别和反应。B细胞是体液免疫的主要效应细胞,而T细胞是细胞免疫的主要效应细胞。巨噬细胞和网状内皮系统的细胞也是免疫系统的一部分,但主要作用于吞噬细胞残核或外源性物质像通过流出管道到达淋巴结的病毒和细菌。网状内皮系统也可清除一些来自循环的多余代谢物。

The enlargement of lymph nodes, either localized or generalized, can be the consequence of several different pathologic mechanisms. Lymphadenopathy may represent an increase in the number and size of lymphoid follicles with proliferation of lymphocytes as a response to a new antigen. There can be enlargement of lymph nodes with infiltration of the node by cells normally not present, such as metastatic tumor or leukemic cells. Lymphadenopathy can occur secondary to unknown stimuli that cause normal cells to become transformed to lymphoma cells and to proliferate autonomously. Lymph nodes can be infiltrated by polymorphonuclear cells, a condition called lymphadenitis, or lymph nodes can be infiltrated by macrophages laden with metabolites, as in lipid storage diseases.

局限性或全身性淋巴结肿大可能是几种不同的病理机制的结果。淋巴结病可呈现为淋巴细胞对新抗原的反应性增生而致淋巴滤泡数量的增多和大小的增大。有的增大淋巴结是因正常不会表达的细胞像恶性肿瘤细胞或白血病细胞浸润而致。淋巴结病可继发于原因不明的刺激导致的正常细胞转变为淋巴瘤细胞并自主增殖。淋巴结可由多形核细胞浸润,称淋巴腺病,或由充满代谢物的巨噬细胞浸润,像脂贮积病。

Clinical Significance临床意义

Table 149.1 Conditions Causing Lymphadenopathy

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