LYMPHADENITIS (lymphadenitis; lat. lympha pure water, moisture + grech, aden of iron + - itis) — the inflammation of lymph nodes arising as a complication of various pyoinflammatory diseases and specific infections (tuberculosis, plague, an actinomycosis). Thus, L., as a rule, is secondary process.
Distinguish L. acute and chronic, specific and nonspecific.
Nonspecific L. most often is caused by stafilokokka, is more rare streptococci and other pyogenic microbes, their toxins and decomposition products of fabrics from primary centers of purulent process. The purulent wound, a furuncle and an anthrax, a felon, an erysipelatous inflammation, osteomyelitis, thrombophlebitis, a trophic ulcer, etc. can be primary centers. In limf, nodes microbes and their toxins arrive lymphogenous, hematogenous and contact in the ways. Penetration of microbes directly in limf, a node is possible at its wound. In such cases of L. acts as primary disease.
Inflammatory process in limf, nodes develops and proceeds on the general type (see. Inflammation ). Depending on character of exudation distinguish serous, hemorrhagic, fibrinous, purulent L. Progressing of a purulent inflammation can lead to destructive forms L. — to abscessing and a necrosis, and at a putrefactive infection — to ichorization limf, nodes. In an initial stage of change come down to damage, exfoliating of an endothelium, expansion of sine, a congestive hyperemia. The begun exudation leads to serous treatment of fabric limf, a node with the subsequent cellular infiltration due to migration of leukocytes and proliferation of lymphoid cells. This stage of serous hypostasis is designated as simple, catarral acute L. At simple L. inflammatory process does not go beyond the capsule limf, a node more often. At destructive forms L. inflammatory process extends to surrounding fabrics (paralymphadenitis). At the same time changes in surrounding fabrics can be limited to a serous inflammation or pass in purulent with formation of an adenoflegmona. Special weight and extensiveness?:» defeats of surrounding fabrics differ ichorous L.
Acute nonspecific lymphadenitis
the Disease begins with morbidity and increase limf, nodes, headaches, weakness, an indisposition, fervescence. Quite often acute L. proceeds with an inflammation limf, vessels (see. Limfangiit ). Expressiveness of signs of acute L. is defined by a form of a disease and the nature of the basic inflammatory process. In some cases during the subsiding of basic process of L. can gain the dominating value in a wedge, a picture. As a rule, at catarral (serous) L. the general condition of patients suffers a little. They note pains in a zone regional limf, nodes, to-rye are increased in sizes, dense and painful at a palpation, are not soldered to surrounding fabrics, skin over them is not changed.
During the progressing of process, development of a periadenitis, transition of an inflammation to a destructive, purulent form specified a wedge, signs are expressed more: pains have sharp character, skin over limf, nodes is hyperemic; the palpation limf, nodes causes morbidity, accurately palpated earlier limf, nodes merge among themselves and surrounding fabrics, become motionless. At the adenoflegmena the diffusion hyperemia, infiltrate, dense without clear boundary, decide on the centers of a softening. The general condition of patients at purulent L. suffers more: temperature increases to high figures, the fever, tachycardia, headaches, the expressed weakness appear. At putrefactive phlegmon determine by a palpation crepitation in the center of defeat.
Complications: thrombophlebitis (see), distribution of purulent process on kletchatochny spaces (retroperitoneal, a mediastinum, etc.), the metastatic centers of a purulent infection — a septicopyemia (see. Sepsis ), limf, fistulas, etc.
Diagnosis put on the basis a wedge, pictures of a disease taking into account anamnestic data. Recognition of superficial L. does not represent difficulties. Diagnosis of L., the complicated by a periadenitis, adenoflegmony with involvement in inflammatory process of intermuscular fatty tissue, kletchatochny spaces of a mediastinum, retroperitoneal space it is difficult. L. it is necessary to differentiate with phlegmon (see), osteomyelitis (see). For the differential diagnosis establishment of primary pyoinflammatory center matters.
Treatment depends on a stage of process. Initial forms L. treat conservatively: rest for the struck body, UVCh-therapy, active treatment of the main center of an infection (timely opening of abscesses, phlegmons, rational drainage of an abscess, opening of purulent zatek), an antibioticotherapia taking into account sensitivity of microbic flora of the main center, and in the absence of an antibiotikogramma prescription of antibiotics of a broad spectrum of activity, semi-synthobiotics. Purulent L. treat by an operational method: open abscesses, adenoflegmona, delete pus, wounds drain. Further treatment is carried out by the principles of treatment of purulent wounds (see. Wounds, wounds ).
Forecast at initial forms L. and timely begun treatment in most cases favorable. Destructive forms L. lead to death limf, nodes with the subsequent substitution by their cicatricial fabric that at localization on extremities can lead to disturbance of a lymph drainage and development lymphostasis (see), and further to elephantiasis (see).
Prevention: injury prevention (wounds, microtraumas), fight against a wound fever, rational treatment of pyoinflammatory diseases.
Chronic nonspecific lymphadenitis
Chronic nonspecific lymphadenitis can be primary and chronic as a result of influence of slabovirulentny microbic flora, at slow, recurrent inflammatory diseases (hron, the tonsillitis, inflammatory diseases of teeth infected attritions of legs, microtraumas, etc.) or an outcome of acute L., when inflammatory process in limf, nodes is not allowed, and accepts long hron, a current. Hron, an inflammation limf, nodes has productive character, its transition to a purulent phase meets extremely seldom. Purulent fusion limf, nodes can be observed at an aggravation of the latent infection which is in them.
Clinical picture: increase limf, nodes, to-rye are dense to the touch, maloboleznenna, are not soldered among themselves and surrounding fabrics. Limf, nodes long remain increased, however eventually growth in them connecting fabric leads to their reduction.
In nek-ry cases the expressed growth of connecting fabric, wrinkling of nodes can lead to frustration of a lymphokinesis, a lymphostasis, hypostases or elephantiasis.
Hron, nonspecific L. it is necessary to differentiate with increase limf, nodes at inf. and nek-ry other diseases (scarlet fever, diphtheria, flu, syphilis, tuberculosis, lymphogranulomatosis, malignant new growths, etc.). Recognition hron. L. shall be based on assessment of all complex a wedge, symptoms of a disease. In doubtful cases the puncture biopsy limf, a node or removal it for gistol, researches is shown that is important especially in differential diagnosis hron. L. and metastasises of malignant new growths.
Treatment it has to be directed to elimination of the basic disease which is a source hron, nonspecific L.
Forecast it is in most cases favorable, an outcome of a disease is scarring: the adenoid tissue is replaced connecting, limf, the node shrivels, decreases in sizes, becomes dense. In some cases elephantiasis can develop.
Prevention: respect for personal hygiene, timely treatment inf. diseases, acute L., increase in body resistance by fortifying treatment.
L concern To group of specific., caused by activators of an actinomycosis, syphilis, tuberculosis, a tularemia, plague, etc. Clinical picture, diagnosis and treatment of main types of specific L. see in articles Actinomycosis , Syphilis , Tularemia , Plague .
Tuberculosis limf, nodes — display of tuberculosis as general disease of an organism (see. Tuberculosis ). More often, especially at children's age, the period of primary tuberculosis is combined with defeat intrathoracic limf, nodes (see. Bronkhadenit ). The isolated defeat of separate groups limf, nodes, a bowl at adults is perhaps relative, against the background of old inactive tubercular changes in other bodies when tubercular L. is display of secondary tuberculosis. Frequency of tubercular L. depends on expressiveness and prevalence of tuberculosis, social conditions. Among children there is a tubercular defeat peripheral limf, nodes, according to E. I. Guseva (1973), P. S. Murashkin (1974), etc., are observed at 11,9 — 22,7% of patients with active forms of extra pulmonary tuberculosis.
Tuberculosis peripheral limf, nodes is caused generally by mycobacteria of tuberculosis of human and bull type. Mycobacteria of bull type usually are the causative agent of tubercular lymphadenitis in the village - x. cattle breeding, districts.
Ways of spread of an infection are various. Given B. P. Aleksandrovsky and soavt. (1936), A. I. Abrikosova (1941), F. L. Elinson (1965), V. A. (R. Kourilsky, 1952), etc., entrance infection atriums almonds can be Firsova (1972), Kuril, at defeat to-rykh are involved in process cervical or Submandibular limf. nodes. The infection most often extends in the limfogematogenny way from the struck intrathoracic limf, nodes, easy or other bodies.
Patomorfol, changes in the struck nodes depend on massiveness of an infection, a condition of an organism of the patient, type of mycobacteria of tuberculosis and other factors. A. I. Abrikosov allocates five forms of tubercular defeat limf, nodes: 1) diffusion lymphoid hyperplasia; 2) miliary tuberculosis; 3) tubercular macrocellular hyperplasia; 4) caseous tuberculosis; 5) indurative tuberculosis. In a wedge, practice the classification offered by N. A. Shmelyov is used, in a cut distinguish three forms of tubercular L.: infiltrative, caseous (with fistulas and without them) and indurative.
At the acute beginning of a disease high temperature, symptoms of tubercular intoxication, increase limf is noted, nodes, it is frequent with the expressed inflammatory and necrotic changes and perifocal infiltration.
Characteristic sign of tubercular L. nodes, existence of a periadenitis is distinguishing it from other defeats limf. Struck limf, nodes represent a conglomerate of the formations of various size soldered among themselves. At adults more often than children, the beginning have diseases gradual, with smaller increase limf, nodes and more rare formation of fistulas in connection with preferential productive character of an inflammation.
The acute beginning of a disease and tendency to bystry education caseose and fistulas connects a number of researchers with infection with bull type of mycobacteria of tuberculosis.
Most often are surprised cervical, submaxillary (Submandibular, T.) and axillary lymph nodes. Several groups limf, nodes with one or from two parties can be involved in process.
Diagnosis put on the basis of comprehensive examination of the patient taking into account existence of contact with tubercular patients, results of reaction to tuberculine (in most cases she is expressed), existence of tubercular defeat of easy and other bodies. An important role for diagnosis is played by these punctures struck limf. node. In limf, nodes the kaltsilata revealed radiological in the form of dense shadows in soft tissues of a neck (fig.), submaxillary area can be formed (a submandibular triangle, T.), axillary and inguinal areas. Tubercular L. differentiate with nonspecific purulent L., lymphogranulomatosis, metastasises of malignant tumors, etc.
Treatment is defined by the nature of defeat limf, nodes and expressiveness of tubercular changes in other bodies. At active process appoint drugs of the first row: Tubazidum, streptomycin in combination with PASK or Etioniamidum, Prothionamidum, Pyrazinamidum, Ethambutolum. Treatment shall be long — 8 — 12 — 15 months
Besides, enter into the struck node (or cut away it) streptomycin, apply bandages with streptomycin, tubazidovy, tibonovy ointment. At the expressed purulent process appoint antibiotics of a broad spectrum of activity. At caseous defeat limf, nodes an operative measure against the background of the general course of antitubercular therapy is shown (see. Tuberculosis ).
The forecast at timely recognition of a disease and treatment of L. favorable.
Prevention of tubercular L. — see Tuberculosis.
Features of lymphadenitis at children
L. it is observed especially often at children of early age. It is connected with funkts, and morfol, imperfection limf, the device of the child (wide sine, the thin gentle capsule limf, nodes, the raised susceptibility to an infection, imperfection of barrier function). L. at children can be nonspecific and specific.
The reasons leading to L. at children, are diverse. L. submaxillary area extremely seldom can be primary disease. Most often it is reaction limf, nodes on inflammatory processes in various centers. Careful identification and sanitation of these centers provide success of further treatment.
At children (especially aged from 1 up to 3 years) at L. most often nodes as through them outflow of a lymph from the most part of the person, an oral cavity and teeth is carried out inflame submaxillary limf. Are surprised mental less often (submental, T.), cervical limf, nodes, are even more rare axillary, subnodal, inguinal and elbow. The inflammation deep limf, nodes is possible (ileal, pelvic, etc.).
It is established that Dontogenous L. occur at children less than not dontogenous. Origin of not dontogenous L. (generally at children of early age) Qatar of upper respiratory tracts, flu, quinsy, hron, tonsillitis, otitis, exudative diathesis, a pyoderma, an injury of skin and mucous membranes are. The source of a dontogenous infection — is more often patients milk, second teeth are more rare.
The most frequent reason of axillary and elbow L. — inflammatory processes in upper extremities (furuncles, felons, contaminated wounds, raschesa, etc.), and inguinal and subnodal — similar processes on the lower extremities.
In a pathogeny of a disease the large role is played by presensitization of an organism as a result of the postponed infections or purulent diseases.
At children of L. proceeds more violently * than at adults, with the expressed signs of the general and local character. Most often the disease begins with temperature increase (to 38 ° above), indispositions, losses of appetite, a headache, a sleep disorder.
At L. maxillofacial area pain and difficulty during the chewing and swallowing is quite often noted. At children of the first years is life and especially chest age in a wedge, to a picture into the forefront symptoms of intoxication act. Cervical and submaxillary L. at this age, as a rule, proceed on ooze of an adenoflegmona with the expressed hypostasis and perifocal reaction.
Ileal L. begin with a febricula, pains in the lower half of a stomach, temperature increase, a flexion contracture of a hip on the party of the same name. Inflammatory infiltrate is located directly over an inguinal sheaf and closely prilezhit to a wing of an ileal bone.
The most serious complications — innidiation of a suppurative focus and development sepsis (see).
Differential diagnosis needs to be carried out with specific processes in limf, nodes and general diseases of blood (a leukosis, a lymphogranulomatosis), tumors. From specific L. at children meet limfadenoaktinomikoz and tuberculosis limf more often. nodes.
At children of early age at defeat inguinal limf, nodes quite often the tumor is taken for the restrained inguinal hernia. Lack of a chair at the restrained hernia, vomiting, the phenomena of intoxication, data rentgenol, researches of an abdominal cavity allow to distinguish hernia from L.
Epiphyseal osteomyelitis of a femur sometimes should be differentiated with an inflammation deep pelvic limf, nodes since high temperature, pains in the field of a hip joint, the flexion bringing contracture of a hip are characteristic of both of these diseases. However at L. in a basin under an inguinal sheaf painful infiltrate is defined, and in a joint all movements of though in limited volume remain.
At a heavy current of H.p. the phenomena of toxicosis, especially at small children, carry out the active infusional therapy directed to removal of intoxication. Appoint antibiotics of a broad spectrum of activity, immunodrugs, the desensibilizing and fortifying therapy. Operational treatment consists in opening and drainage of inflammatory infiltrate; it is made, without waiting for a softening. If pus is not emitted, in a wound leave for days the rubber graduate. It is not necessary to do big cuts. The section of 2 — 3 cm in size is most often quite sufficient for opening of a purulent cavity. Only extensive adenoflegmona are the indication for wider cuts. Locally apply proteolytic enzymes at co-administration of physical therapy.
The forecast at timely and appropriate treatment favorable.
Prevention: actions for a hardening of an organism of the child, timely treatment of the inflammatory centers, to-rye can be the cause of L.
Bibliography: Voyno-Yasenetsky V. F. Sketches of purulent surgery, L., 1956; Davydovsky I. V. General pathology of the person, page 408, M., 1969; Diagnosis of surgical diseases, under the editorship of V. S. Levitte, page 417, M., 1959; D m and t-R and e in M. L., Pugachev A. G. and N. L Kushch. Sketches of purulent surgery at children, M., 1973, bibliogr.; D about l of e of the Central Committee and y S. Ya. and And with and to about in Yu. F. Children's surgery, p.1, page 194, M., 1970; Buttocks r about in S. Gnoyno - septic surgery, the lane with bolg., page 171, Sofia, 1977; Pokhitonova M. P. Clinic, treatment and prevention of tuberculosis at children, M., 1965; V. I Pods. Purulent surgery, page 71, M., 1967.
V. I. Struchkov, V. K. Gostishchev; A. F. Dronov (it is put. hir.), V. A. Firsova (ftiz.).