Enlargement of lymph nodes and spleen

The clinical evaluation of patients with myeloma includes a careful physical examination searching for tender bones and masses. Only a small minority of patients has an enlargement of the spleen and lymph nodes, the physiologic sites of antibody production. Chest and bone radiographs may reveal lytic lesions or diffuse osteopenia. MRI offers a sensitive means to document extent of bone marrow infiltration and cord or root compression in patients with pain syndromes. A complete blood count with differential may reveal anemia. Erythrocyte sedimentation rate is elevated.

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The absence of the spleen has minimal long-term effects on the hematologic profile. In the immediate postsplenectomy period, leukocytosis (up to 25,000/µL) and thrombocytosis (up to 1 x 106/µL) may develop, but within 2–3 weeks, blood cell counts and survival of each cell lineage are usually normal.

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Differential Diagnosis Many of the diseases associated with splenomegaly are listed in Table 60-2. They are grouped according to the presumed basic mechanisms responsible for organ enlargement: 1.

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The differential diagnostic possibilities are much fewer when the spleen is "massively enlarged," palpable more than 8 cm below the left costal margin or its drained weight is ≥1000 g (Table 60-3). The vast majority of such patients will have non-Hodgkin's lymphoma, chronic lymphocytic leukemia, hairy cell leukemia, chronic myelogenous leukemia, myelofibrosis with myeloid metaplasia, or polycythemia vera.

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Approach to the Patient: Splenomegaly Clinical Assessment The most common symptoms produced by diseases involving the spleen are pain and a heavy sensation in the LUQ. Massive splenomegaly may cause early satiety. Pain may result from acute swelling of the spleen with stretching of the capsule, infarction, or inflammation of the capsule. For many years it was believed that splenic infarction was clinically silent, which at times is true.

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Splenomegaly Structure and Function of the Spleen The spleen is a reticuloendothelial organ that has its embryologic origin in the dorsal mesogastrium at about 5 weeks' gestation. It arises in a series of hillocks, migrates to its normal adult location in the left upper quadrant (LUQ), and is attached to the stomach via the gastrolienal ligament and to the kidney via the lienorenal ligament. When the hillocks fail to unify into a single tissue mass, accessory spleens may develop in around 20% of persons. The function of the spleen has been elusive.

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Laboratory Investigation The laboratory investigation of patients with lymphadenopathy must be tailored to elucidate the etiology suspected from the patient's history and physical findings. One study from a family practice clinic evaluated 249 younger patients with "enlarged lymph nodes, not infected" or "lymphadenitis." No laboratory studies were obtained in 51%. When studies were performed, the most common were a complete blood count (CBC) (33%), throat culture (16%), chest x-ray (12%), or monospot test (10%).

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Harrison's Internal Medicine Chapter 60. Enlargement of Lymph Nodes and Spleen Enlargement of Lymph Nodes and Spleen: Introduction This chapter is intended to serve as a guide to the evaluation of patients who present with enlargement of the lymph nodes (lymphadenopathy) or the spleen (splenomegaly). Lymphadenopathy is a rather common clinical finding in primary care settings, whereas palpable splenomegaly is less so.

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