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淋巴结病第二部分

(2009-05-22 22:52:16)
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健康

接第一部分。

Table 149.1

Conditions Causing Lymphadenopathy导致淋巴结病的条件

 

Infections感染

Localized: a response to a local infection such as streptococcal pharyngitis

局限:对局限性感染的反应像链球菌咽炎

Generalized: a response to a systemic infection such as tuberculosis, syphilis, infectious mononucleosis, hepatitis, fungal infection, toxoplasmosis, HIV, etc.

   全身:对系统性感染的反应像结核菌病、梅毒、传染性单核细胞增多症、肝炎、霉菌感染、弓形虫病、HIV等。

Immunologic conditions免疫状况

Known antigens such as drug reactions or serum sickness

抗原已知的像药物反应或血清病

Unknown antigens such as in sarcoidosis

  抗原不明的像结节病

Connective tissue disease such as rheumatoid arthritis, systemic lupus erythematosus

   结缔组织病像类风湿关节炎、系统性红斑狼疮

Miscellaneous: giant lymph node hyperplasia, dermatopathies, lymphadenitis,

  多方面:巨大淋巴结增殖、皮肤病、淋巴结炎、免疫母细胞淋巴结病

Malignant processes恶性进程

Diffuse involvement, as in lymphomas and leukemias

  本身可播散的,像淋巴瘤和白血病

Diffuse invasion, as in diffuse carcinomatosis

  侵袭性播散,像癌扩散

Localized invasion, as in head and neck tumors

  局限性侵袭,像头颈部肿瘤

Lipid storage diseases脂贮集病

Miscellaneous 多方面的

Graves" and Addison's diseases

 

Given the mechanisms by which lymph nodes enlarge, it is clear that the differential diagnosis of lymphadenopathy involves infectious processes, immunologic conditions, malignant processes, storage diseases, and a variety of miscellaneous disorders (Table 149.1).

通过淋巴结增大的机制,清楚地了解到淋巴结的鉴别诊断涉及感染过程、免疫状态、恶性进展和各种各样的紊乱。

Information from the clinical history is invaluable in the diagnostic management of the patient with lymphadenopathy, and frequently leads to an accurate diagnosis without the need for extensive diagnostic testing. The age of the patient is quite important. Dramatic enlargement of lymph nodes and other lymphoid tissue such as the adenoids and tonsils is often a normal response to a variety of relatively weak antigenic stimuli such as mild viral and bacterial infections or vaccinations in infants and children, whereas in adults these antigens will not elicit a generalized response. This age difference in the expression of lymphadenopathy is of such importance as to warrant an almost totally different diagnostic approach to patients before and after puberty.

来自病史的信息在诊断淋巴结病的病人中价值非常大,并通常能够做出准确的诊断而不需大量的诊断试验。病人的年龄十分重要。在婴儿和儿童显著增大的淋巴结或其他的淋巴组织像扁桃体常常是对各种相对弱抗原刺激像轻度病毒和细菌感染或接种疫苗,然而在成人这些抗原将不会引起全是性反应。年龄的差异在淋巴结病非常重要可成为对青春期前后病人不同诊断的依据。

Specific inquiries should be made about drugs, allergies, animal exposures, hobbies, and occupation. Lymphadenopathy as an adverse response to drugs and allergies is well recognized. Exposure to cats may raise a question of cat-scratch fever in a patient who presents with unilateral lymphadenopathy of an extremity. Enlarged, nontender lymph nodes in the epitrochlear, axillary, femoral, and inguinal areas are often seen in patients with occupations in which recurrent, usually minor, injuries to extremities occur. Generalized lymphadenopathy also can occur in patients with such chronic dermatologic disorders as eczema. If acquired immune deficiency syndrome (AIDS) is suspected, information must be obtained concerning potential risk factors for this disorder: sexual preference, contact with individuals with the disorder, transfusion of blood products, etc.

特殊病史关于药物、过敏症、动物接触、嗜好、和职业。药物不良反应或过敏而致的淋巴结病很好辨别。和猫有过接触肢体单侧淋巴结病的病人可能和猫爪热有关。在滑车上、腋窝、股窝、腹股沟区增大的、无痛的淋巴结病人常有从事反复的、经常是四肢微小创伤发生的职业。全身淋巴结病也可发生在有慢性皮肤性紊乱像湿疹病人中。如果怀疑是获得性免疫缺陷病(AIDS),有关这方面的潜在危险因素的信息必须采集:性偏好、和有此病个体的接触史、输入过血制品等。

Information must also be obtained about the lymphadenopathy itself. Tender, painful nodes that appear and enlarge within a few days to a few weeks are most often secondary to an inflammatory process in the area drained by the lymph nodes. Occasionally a patient with tender, rapidly enlarging lymphadenopathy will have lymphoma or leukemia. However, slowly growing, nontender nodes may be indicative of either local or generalized malignancy.

关于淋巴结病本身的信息也应采集。发现增大几天或几周的质软、疼痛的淋巴结常见于继发于淋巴结流出区域的继发感染。偶尔病人柔软、快速增大的淋巴结提示淋巴瘤或白血病。然而,缓慢增长、无痛性淋巴结可能提示局部或全身恶性肿瘤。

A careful history must be taken regarding constitutional symptoms including fever, night sweats, weight loss, pruritus, and generalized malaise. These symptoms can be associated with either malignancies or infectious processes such as tuberculosis or hepatitis.

详细的病史关于全身症状需要采集,包括发热,盗汗,消受,搔痒及全身的不适。这些症可和恶性肿瘤或感染性疾病像集合结核或肝炎有关。

Specific symptoms such as cough may raise the question of tuberculosis or fungal pulmonary infection; a history of jaundice or clay-colored stools should raise the question of hepatitis. Usually any diagnosis or condition suggested by the history requires corroboration by data from the physical examination and appropriate laboratory tests or lymph node biopsy. Infectious processes can be localized, as in a response to a local abscess or to cellulitis. When the infection is systemic in nature, the lymphadenopathy is also usually generalized, as in tuberculosis, brucellosis, infectious mononucleosis, hepatitis, fungal infections, and toxoplasmosis.

特殊症状像咳嗽可提出肺部结核或霉菌感染;黄疸或陶土样便应该考虑到肝炎。通常通过病史的诊断或条件需要体格检查和适当的实验室检查或淋巴结活检的证据。感染进程可以局限像在局限性脓肿或蜂窝织炎的反应中。当感染的性质是全市性的,淋巴结病常也是全身的,如在结核病、布鲁菌病、传染性单核细胞增多症、肝炎、霉菌感染和弓形虫病。

Immunologic conditions that cause lymphadenopathy can be secondary to clearly identified antigens, as in serum sickness, or a response to an insect bite, or the lymphadenopathy may be secondary to antigenic stimulation in conditions where the antigen has not been identified. Examples of the latter include the connective tissue disorders including rheumatoid arthritis and systemic lupus erythematosus. Sarcoidosis is another example of an immunologic process that causes widespread lymphadenopathy, although the causative antigen has not yet been identified.

导致淋巴结病的免疫条件可继发于明确的抗原,如在免疫复合物血清病、动物咬伤的反应或继发于抗原不明的抗原刺激。后者包括结缔组织病像类风湿性关节炎和系统性红斑狼疮。结节病是免疫病导致广泛淋巴结病的另一个例子,尽管致病抗原还不明确。

A recently recognized viral (HIV) cause of lymphadenopathy is a systemic infection causing severe immunologic deficiencies in the host. This syndrome has been labeled the AIDS complex. Unexplained generalized adenopathy should raise the possibility of AIDS or AIDS-related complex, and the individual should be carefully uated for possible risk factors. Blood samples for viral titers should also be obtained.

最近公认的病毒(HIV)导致的淋巴结病是一个系统性感染导致宿主严重的免疫缺陷病。这个症状称为AIDS综合症。不明原因的全身淋巴结肿大应该考虑AIDS或AIDS相关综合症的可能性,并且这个人的相关危险因素应被仔细评估。血标本和病毒滴度应被采集。

Invasion by malignant cells can cause either regional lymphadenopathy, as in patients with head and neck tumors, or generalized lymphadenopathy, as in patients with disseminated carcinomatosis. Lymphoma can also result in either regional or generalized lymphadenopathy.

恶性细胞侵犯可导致局部淋巴结病如在头颈部肿瘤的病人中,也可是全身性淋巴结病如在播散性癌转移的病人中。淋巴瘤可导致局部或全身淋巴结病。

Generalized lymphadenopathy may also be the result of a variety of other conditions, including Gaucher's disease, Graves" disease, and Addison's disease.

全身性淋巴疾病也可是各种其他状况的结果,包括Gaucher疾病、Graves病、 Addison病。

In most patients with lymphadenopathy, a diagnosis can be made after a careful history, physical examination, and appropriate testing including hematologic parameters, serologic tests, skin tests, and routine x-rays. As in all diagnostic work-ups, these tests should be performed in a goal-directed manner in order to uate specific hypotheses. If a specific diagnosis cannot be established after appropriate uation, but infection is suspected, cautious observation after appropriate cultures have been obtained may be warranted. Indiscriminant use of antibiotics for unsubstantiated infections should not be encouraged. On the other hand, if the diagnosis cannot be established and a malignancy is a major concern, biopsy of a lymph node is appropriate and should be done in a timely fashion. When a biopsy is done, adequate tissue should be obtained for both histologic examination and appropriate cultures. Occasionally, more than one node may have to be biopsied in order to determine the appropriate diagnosis. Occasionally, nodes will reveal only nonspecific lymphoid hyperplasia, whereas a neighboring node will harbor metastatic tumor. If an inadequate specimen is obtained, the malignant disease may not be diagnosed.

在大多数淋巴结病的病人中,在认真的病史采集、体格检查及合适的检查像血常规、血清实验、皮肤试验和常规X线后可作出诊断。在所有的诊断性检查中,需要对可能的情况做有目的的检查。如果在恰当的检查后明确的诊断不能作出,但是怀疑感染,在恰当的培养作出后细心地观察可能是保证。试验性的抗生素应用在没有客观证据的感染中是不被支持的。另一方面,如果诊断不能明确又主要考虑恶性肿瘤,及时活检淋巴结是合适的。当做活检时,应切取足够的淋巴结以用于组织学检查和合适的培养。偶尔,活检不止一个淋巴结以作出恰切的诊断。偶尔,淋巴结仅表现为非特异性淋巴组织增生,然而临近淋巴结隐匿恶性肿瘤。如果取的标本不合适,恶性疾病就可能漏诊。

In conclusion, although the differential diagnosis of lymphadenopathy may be broad and sometimes initially confusing, the careful gathering of data from the history, physical, and appropriate laboratory tests will resolve the differential in the vast majority of patients.

总之,尽管淋巴结病的鉴别诊断可能涉及很广并且有时开始时令人困惑,仔细的从病史、体检、合适的实验室检查收集的数据将决定大部分病人的鉴别诊断。

 

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