Lymphadenopathy is very common among HIV-infected individuals and may occur at any stage of HIV infection. It may be the first indication of a serious local or systemic condition, and it should be evaluated carefully. Rapid enlargement of a previously stable lymph node or a group of nodes requires evaluation to identify the cause and to determine whether treatment is needed. Similarly, nodes that are abnormal in consistency, tender to palpation, fluctuant, asymmetrical, adherent to surrounding tissues, or accompanied by other symptoms should be evaluated promptly.
Lymphadenopathy may be generalized or localized and usually is characterized by lymph nodes that are >1 cm in diameter. A multitude of conditions can cause lymphadenopathy, including HIV itself, opportunistic or other infections, and malignancies. The likely causes of lymphadenopathy, and thus the diagnostic workup, will depend in part on the patient's degree of immunosuppression. The risk of opportunistic and certain malignant conditions increases at lower CD4 cell counts (see chapter Risk of HIV Progression/Indications for ART).
Many individuals with primary HIV infection (see chapter Primary HIV Infection) have generalized lymphadenopathy that may resolve or may persist for months to years. If lymphadenopathy of >2 cm in size occurs in two or more noncontiguous sites and persists for more than 3 months, and if appropriate evaluation reveals no other cause, the patient is diagnosed with persistent generalized lymphadenopathy (PGL). PGL usually is caused by follicular hyperplasia from chronic HIV infection. As long as enlarged nodes are stable in number, location, and size, persons with PGL require no specific management other than monitoring of nodes at each physical examination (though consideration should be given to initiation of antiretroviral therapy [ART]). Changes in the character of the lymph nodes should prompt further evaluation. Rapid involution of PGL may occur with advanced HIV disease and is a poor prognostic sign.
The patient complains of new, worsening, or persistent glandular swellings in the neck, axilla, groin, or elsewhere.
Ascertain the following during the history:
The differential diagnosis of lymphadenopathy in HIV-infected patients depends in part on the degree of immunosuppression. For further information, see chapter Risk of HIV Progression/Indications for ART.
After the history and physical examination, the cause of lymphadenopathy may be clear and further diagnostic testing may not be necessary. If the cause of the lymphadenopathy is still uncertain, perform diagnostic testing as indicated by the patient's presentation. This may include the following tests:
If a node is large, fixed, nontender, or otherwise worrisome, or if the diagnosis is unclear after initial evaluation, fine-needle aspiration (FNA) biopsy may provide a diagnosis. If FNA is nondiagnostic (false-negative results are relatively common), obtain an excisional biopsy for definitive evaluation. Biopsy specimens should be sent for bacterial, mycobacterial, and fungal cultures; acid-fast staining for mycobacteria; and cytologic examination.
If a node is large, inflamed, tender, or fluctuant, and a bacterial infection is suspected, consider initiating empiric antibiotic treatment and monitoring the patient over the course of 1-2 weeks. If the node does not respond to antibiotic treatment or the patient becomes more symptomatic, arrange for FNA or open biopsy to establish the diagnosis.
Treatment will depend on the cause of lymphadenopathy. Refer to section Comorbidities, Coinfections, and Complications or to OI management guidelines as appropriate. In the case of HIV-related lymphadenopathy, ART may be effective.