Persistent generalized lymphadenopathy PGL

PGL is a feature of HIV infection which develops in up to 50% of HIV-infected individuals. It is of no prognostic significance.There is no specific treatment.The diagnostic criteria for PGL are as follows: lymph nodes larger than

1 cm in diameter in 2 or more extra-inguinal sites for 3 or more months.

The nodes are non-tender, symmetrical, and often involve the posterior cervical and epitrochlear nodes. PGL may slowly regress during the course of HIV infection and may disappear before the onset of AIDS. In populations with a high HIV prevalence, PGL is the commonest cause of lymphadenopathy. In HIV-positive individuals PGL is a clinical diagnosis. Only investigate further if there are features of another disease. The features of lymph nodes that indicate a need for further investigation, including biopsy, are:

° large (> 4 cm diameter) or rapidly growing lymph nodes ° asymmetrical lymphadenopathy

° tender/painful lymph nodes not associated with local infection ° matted/fluctuant lymph nodes

° obvious constitutional features (e.g. fever, night sweats, weight loss) ° hilar or mediastinal lymphadenopathy on CXR.

Practical approach to investigation of lymphadenopathy

(if clinical features suggest a cause of lymphadenopathy other than PGL).

Procedure

Test

Result

Diagnosis

look at material -►

caseation

TB

aspirated

needle

smear for

AFB present

TB

aspirate

AFB

of lymph

node

smear for

malignant

malignancy

cytology

cells seen

e.g. KS,

lymphoma,

carcinoma

if no diagnosis after aspirate

look at cut

caseation

TB

surface

smear from cut -►

AFB seen

TB

surface for AFB

lymph

node

fresh node

positive

TB

biopsy

sent for

TB culture

TB culture

node in

granuloma

TB

formalin

and AFB

for histology

malignant

malignancy

cells

Diagnosis of tuberculous lymphadenopathy is possible even without laboratory facilities for histology or TB culture. Diagnostic sensitivity of tuberculous lymphadenopathy by aspirate and smear for AFB is 70%. Diagnostic sensitivity increases to 80% if you excise a lymph node, look at the cut surface, and do a smear for AFB.

The histological appearance of tuberculous lymph nodes from HIVpositive patients depends on the degree of immunocompromise, as shown below.

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