Thread by @hematogones

Something for the new path residents starting their journey

An A-Z of lymph node pathology

Some nice pictures of different lymph node pathology that you can commit a neuron or two?

One letter each day.

#hemepath #pathology #lymphnode #hematology #FOAMed

An A-Z of lymph node pathology.

[A] Amyloidosis => Look in nodes from patients with MZL, LPL or plasma cell neoplasms

Ref: ncbi.nlm.nih.gov/pubmed/3539760

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An A-Z of lymph node pathology.

[A] Angiomyomatous hamartoma => Usually incidentally enlarged inguinal node in young males ... bands of smooth muscle reaching to edge of cortex +/- hilar fat.

Ref: iv.iiarjournals.org/content/26/3/4…

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An A-Z of lymph node pathology:

[B] Bacillary Angiomatosis => Less common in developed countries with wider availability of HAART HIV therapy, but still present in HIV endemic areas.

Ref: ncbi.nlm.nih.gov/pmc/articles/P…

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An A-Z of lymph node pathology:

[B] Burkitt Lymphoma => 90% w/ MYC rearrangement, but MYC-neg cases may carry 11q aberrations. Bcl2/Tdt neg + MYC protein pos at high levels can help with the ddx.

Ref: ncbi.nlm.nih.gov/pubmed/24398325

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An A-Z of lymph node pathology:

[C] Castleman disease => HV: common, usu localized, may cause unexplained anemia; PCV: can be multifocal, more aggressive, think HIV/HHV8 (Kaposi sarc)

Ref: ncbi.nlm.nih.gov/pubmed/19546611

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An A-Z of lymph node pathology:

[D] Dermatopathic lymphadenopathy => Kids -> ddx w/ LCH (DL is cyclinD1 neg). Adults -> think of MF.

Also here:

https://twitter.com/hematogones/status/986993527774203904

Ref: ncbi.nlm.nih.gov/pubmed/28622183

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An A-Z of lymph node pathology:

[D] Dilantin adenopathy => Changes may simulate cat-scratch, Kikuchi or lymphoma ... history of seizure disorder and timing with medication is key!

Ref: ncbi.nlm.nih.gov/pubmed/4137045

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An A-Z of lymph node pathology:

[E] EBV lymphadenitis -> EBV ISH should be positive in variably sized B-cells, unlike in lymphoma where all EBV pos B-cells are same size.

Ref: ncbi.nlm.nih.gov/pubmed/21320728

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An A-Z of lymph node pathology:

[F] Fujimoto-Kikuchi lymphadenitis 😉 -> Similar histo to SLE adenitis. MPO stain is neat way to highlight crescenteric histiocytes in KFH, unlike T-cell lymphomas

Ref: ncbi.nlm.nih.gov/pubmed/11549584

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An A-Z of lymph node pathology:

[G] Gaucher's disease ->Classic combination of young age, failure to thrive and organomegaly in liver, spleen and nodes. Rare... but exciting when you catch it.

Ref: ncbi.nlm.nih.gov/pubmed/18466035

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An A-Z of lymph node pathology:

[H] Herpes lymphadenitis -> Typical changes are punctate, neutrophilic abscesses with rare inclusions.

Sometimes can be seen as local reactivation in CLL nodes! 👇

Ref: ncbi.nlm.nih.gov/pubmed/?term=1…

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An A-Z of lymph node pathology:

[I] Immunodeficiency: HIV w/ follicle lysis -> hyperplasia + germ center hemorrhagic lysis. With right history, always 👀 for Kaposi or Toxo changes in background

Ref: ncbi.nlm.nih.gov/pubmed/3876855

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An A-Z of lymph node pathology:

[I] Immunodeficiency: Congenital immunodef. -> "Empty looking nodes" with few follicles +/- GCs, 🔼plasma cells & 🔽 T-cells. +/- Granulomas. Incr risk of lymphoma

Ref: ncbi.nlm.nih.gov/pubmed/?term=2…

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An A-Z of lymph node pathology:

[J] Jirovecii (Pneumocystis) adenitis 😉-> Necrotizing granulomas, "bubbly" histiocytes, few neutrophils. Uniform size + 🚫 budding argues against Histo

Ref: archivesofpathology.org/doi/full/10.10…

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An A-Z of lymph node pathology:

[K] Kawasaki adenopathy: Rarely nodal disease with fevers is 1st presentation. Mottled node w. microangiopathic vascular thrombus + ischemic changes.

Ref: ncbi.nlm.nih.gov/pmc/articles/P…

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An A-Z of lymph node pathology:

[K] Kimura disease: Benign inflammatory adenopathy with peripheral eosinophilia. Hyperplastic follicles + prominent vessels + eos & polykaryocytes.

Ref: ncbi.nlm.nih.gov/pubmed/17425383

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An A-Z of lymph node pathology:

[K] Kaposi sarcoma: HIV+ patients with HHV8 coinfection. I was once schooled by a Hungarian colleague that name is pronounced Kap-o-Shee, not kap-Oh-seeeee.

Ref: archivesofpathology.org/doi/pdf/10.585…

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An A-Z of lymph node pathology:

[L] Lepromatous leprosy: Prevalent in developing parts of the world. Highlight in paraffin tissues or direct smears as weakly acid fast or, better with Fite stain.

Ref: cltri.gov.in/TrainingMateri…

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An A-Z of lymph node pathology:

[L] Leishmaniasis (Visceral): Can rarely find granulomas with intracellular "dots in spaces" pattern. Highlight with Giemsa stains on thinly sectioned slides or touch imprints fixed in EtOh.

Ref: archivesofpathology.org/doi/pdf/10.104…

An A-Z of lymph node pathology:

[M] Mastocytosis: Lymph node involvement usu in systemic forms. Sometimes see concurrent marked 🔼 in eos. CD117/CD25+ phenotype, often with KIT-D816V mutation.

Ref: academic.oup.com/ajcp/article/1…

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An A-Z of lymph node pathology:

[N] Nodular LP HL: CD20+ B-cell lymphoma with "mass in mass" pattern of effacement and 🔼 PD-1+ T-fh cells. DDX: cHL and TCRLBCL

Note: variant patterns 👇🏾!!!

Ref: ncbi.nlm.nih.gov/pubmed/14508396

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An A-Z of lymph node pathology:

[O] Old Man Groin Node: Look, I did my best. Read all my lymph node books. Googled for an hour. This is the best I could come up with.

Authoritative reference👇🏾

Ref: ncbi.nlm.nih.gov/pubmed/12973685

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An A-Z of lymph node pathology:

[P] Proteinaceous Lymph node: Rare⚠️Extracellular nonamyloid Ig deposits causing enlargement -> can be associated with plasma cell dyscrasia or rheumatic disease

Ref: ncbi.nlm.nih.gov/pubmed/2294866

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An A-Z of lymph node pathology:

[P] Progressive transformation of germinal centers: Disruption of GCs by mantle zone -> Not precursor to NLPHL, but can explain persistent adenopathy.

Ref: ncbi.nlm.nih.gov/pubmed/26410017

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An A-Z of lymph node pathology:

[Q] Quinsy (aka peritonsillar abscess 😏 --> Okay, I cheated a bit for this letter and used a tonsil. Take a peek for HSV on your next quinsy...you might be surprised

Ref: ncbi.nlm.nih.gov/pubmed/17141448

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Bonus #1: Quinsy --> derived from Greek kynankhe = "choking-dog"

Bonus #2: Check out this nice paper on Herpesvirus tonsilitis by @HeadandNeckPath and colleagues

Ref: ncbi.nlm.nih.gov/pubmed/24338612

An A-Z of lymph node pathology:

[R] Rosai-Dorfman disease (of course!) --> Dr. Dorfman once impressed upon me that if one doesn't see lots of plasma cells, don't make this diagnosis.

Ref: ncbi.nlm.nih.gov/pubmed/26966089

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Rosai-Dorfman Disease Bonus time!

Bonus #1: See this nice obituary of this giant of lymph node pathology: stanfordmedicine.com/news/all-news/…

Bonus #2: Dr. Dorfman once showed me this slide of apparent RDD arising in a lion! 👇🏾

An A-Z of lymph node pathology:

[S] Sarcoidosis --> Tightly formed granulomas, usually without necrosis. Focal punctate necrosis can be seen on occasion. Be careful with GMS though !👇🏾

Ref: ncbi.nlm.nih.gov/pmc/articles/P…

#hemepath #pathology #lymphnode #IDpath #FOAMed

An A-Z of lymph node pathology:

[T] Toxoplasma adenitis: 3 acts -> florid hyperplasia + histiocyte clusters push germinal centers + monocytoid B-cell expansion. Serology + history >> IHC

Ref: jcp.bmj.com/content/jclinp…

#hemepath #pathology #lymphnode #hematology #FOAMed

Toxoplasma adenitis bonus time!

Bonus #1: The triad 1st described in 1958 by Piringer-Kuchinka and Saxen, independently

Bonus #2: Dr. Dorfman was able to get a 🚨 NEJM 🚨pub on a pure histology paper (with 21 cases)!! Damn times have changed.

Reference: ncbi.nlm.nih.gov/pubmed/?term=4…

An A-Z of lymph node pathology:

[U] Ummm... Ummm... Let me see here.... No... I can't find something for the letter.

I got nothin.

Here are some pictures of puppies in sunglasses for no reason instead.

An A-Z of lymph node pathology:

[V] Vascular transformation of lymph nodes: Vasoproliferative lesion of lymph nodes --> may explain persistent adenopathy and be associated w/ prior LN dissection.

Ref: ncbi.nlm.nih.gov/pubmed/2069211

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An A-Z of lymph node pathology:

[V] Visceral larva migrans: Toxocara larvae induced eosinophilic macroabscesses +/- Splendore-Hoeppli reaction. Similar changes with any metazoan larvae in nodes.

Ref: ncbi.nlm.nih.gov/pmc/articles/P…

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An A-Z of lymph node pathology:

[W] Whipple lymphadenopathy: Characteristic low-power "lymphangiogram" pattern of open cystic spaces + granular histiocytes. Gram+/Pasd+ organisms.

Ref: ncbi.nlm.nih.gov/pmc/articles/P…

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An A-Z of lymph node pathology:

[Y] Yersinia lymphadenopathy: Characteristic epithelioid necrotizing granulomas localized to the germinal centers. Mesentery and bowel lymph nodes are common.

Ref: jstage.jst.go.jp/article/jslrt/…

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An A-Z of lymph node pathology:

[Z] Z... Zee... Zed... Zeta. The last letter of the english alphabet, also the end of this tweetorial. It was fun and I hope some of you found it useful.

The entire image series will be available at hematogones.com soon.

#hemepath