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symptom.lymphadenopathy.v1

Lymphadenopathy (localised / generalised / by location + features)

symptomsubacutechronicundifferentiatedadultoutpatientinpatient
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Phase C shard-3-neuro-sym deepening pass (2026-05-14) — full §5.5 contract depth. Pattern peer: symptom.vertigo.v1. Engine scope: triage + biopsy-decision for palpable / imaging-detected lymphadenopathy across primary care + ED + inpatient. Downstream routes to heme-onc / ID / rheumatology / dermatology per diagnosis. Co-routes with symptom.fuo.v1 (the only verified sibling in ALL_DOSSIERS). Bayesian linkage (location + features × LR+ × LR− × ddx, pre-test priors by location, T_treat / T_test thresholds, conditional dependencies) lives in companion depth bundle _briefs/symptom.lymphadenopathy.v1.depth.md. 5 setting playbooks (home, ed, icu, inpatient, outpatient). 11 severity triggers (≥6 per spec): localized_reactive_lymphadenopathy + generalized_lymphadenopathy_workup + supraclavicular_high_concern + b_symptoms_present + cytopenia_with_lymphadenopathy + hard_fixed_painless_node + rapidly_enlarging_node + mediastinal_mass_airway_compression + pediatric_phenotype_concerning + drug_induced_dress + airway_compromise_lad. 1 sibling differentiation row (symptom.fuo.v1 — verified in ALL_DOSSIERS). Splenomegaly + neck-mass-incidental siblings surfaced as pivots in depth bundle (no dedicated engines yet). Schema-blocked items surfaced: Ann Arbor / Lugano stager, IPI / FLIPI / IPS calculators, Lugano response criteria codifier, ECOG PS — none in clinical-tools-registry.ts. Cross-shard tickets to shard-0. Modern view captured: excisional biopsy preferred over FNA for lymphoma (Lugano Cheson 2014 PMID 25113753); steroid AVOIDANCE until lymphoma excluded; supraclavicular ANY size = >90% pathologic; DRESS = drug + LAD + rash + eos + LFT rise (RegiSCAR 2013). PMIDs (8): Bazemore AFP 2002 (12484692), Habermann NEJM 2002 (9803196), Lugano Cheson 2014 (25113753), Engert NEJM 2010 (32703949), Florin cat-scratch 2008 (21243990), Mohapatra TB 2009 (20209720), Cohen EBV 2000 (10944566), Kardaun DRESS 2013 (23855313). All marked NEEDS_SOURCE_REVIEW per shard convention.

Entry points (8)

  • symptom
    Palpable lymph node noted by patient or clinician (Bazemore AFP 2002 PMID 12484692)
    palpable_node_concern
  • imaging
    Incidental lymphadenopathy on imaging (NCCN 2024)
    incidental_lymphadenopathy
  • symptom
    Lymphadenopathy + B symptoms (fever, night sweats, >10% weight loss / 6 mo) — lymphoma signature (Lugano Cheson 2014 PMID 25113753)
    b_symptoms_with_node
  • symptom
    Supraclavicular node any size — highly concerning (>90% pathologic in adults; Virchow = abdominal malignancy)
    supraclavicular_node_any_size
  • symptom
    Generalized LAD ≥2 non-contiguous regions — HIV / mono / lymphoma / leukemia / drug / autoimmune (Habermann 2002 PMID 9803196)
    generalized_lymphadenopathy
  • imaging
    Hilar / mediastinal lymphadenopathy on imaging — sarcoidosis / TB / lymphoma / lung cancer
    hilar_mediastinal_lad
  • symptom
    Rapidly enlarging LAD + cytopenia / blasts on smear — acute leukemia / aggressive lymphoma (NCCN 2024)
    rapidly_enlarging_node_with_cytopenia
  • symptom
    New drug + LAD + rash + eosinophilia + LFT rise → DRESS (RegiSCAR Kardaun 2013 PMID 23855313)
    drug_lad_rash_eosinophilia

Required inputs (34)

  • agerequired
    demographic • used at CONTEXT
    Age >40 raises malignancy prior; pediatric mostly reactive (Bazemore AFP 2002 PMID 12484692)
  • sex
    demographic • used at CONTEXT
    Lymphoma sex distribution + breast / GU drainage relevance (Habermann 2002)
  • node_locationrequired
    symptom • used at FRAME
    Supraclavicular = highly concerning at any size; cervical / axillary / inguinal / hilar / mesenteric — different drainage + dx (Bazemore 2002 PMID 12484692)
  • node_distributionrequired
    symptom • used at FRAME
    Localised (single region) vs generalised (≥2 non-contiguous) — narrows differential (Habermann 2002 PMID 9803196)
  • node_sizerequired
    symptom • used at FRAME
    ≥1.5 cm persistent or ANY supraclavicular → biopsy threshold (Bazemore 2002; Lugano Cheson 2014)
  • duration_trajectoryrequired
    symptom • used at CONTEXT
    <2 wk reactive likely; >4-6 wk pathologic prior; doubling in weeks → aggressive (Bazemore 2002)
  • consistencyrequired
    symptom • used at FRAME
    Hard / matted / fixed = malignancy; rubbery = lymphoma; tender = infection (Habermann 2002)
  • tendernessrequired
    symptom • used at FRAME
    Tender → infectious / acute; painless → malignant prior shifts up (Bazemore 2002)
  • b_symptomsrequired
    symptom • used at CONTEXT
    Fever, drenching night sweats, ≥10% weight loss in 6 mo → lymphoma signature (Lugano Cheson 2014 PMID 25113753)
  • pruritus_alcohol_pain
    symptom • used at CONTEXT
    Hodgkin classic: pruritus + alcohol-induced nodal pain (Engert NEJM 2010 PMID 32703949)
  • travel_animal_sick_contactsrequired
    history • used at CONTEXT
    Bartonella cat (Florin Klotz 2008 PMID 21243990), Toxoplasma cat litter, Brucella livestock, TB endemic (Mohapatra 2009 PMID 20209720), tularemia rabbit
  • sexual_historyrequired
    history • used at CONTEXT
    HIV / syphilis / HSV — generalised LAD common (Habermann 2002)
  • autoimmune_history
    history • used at CONTEXT
    SLE, RA, sarcoidosis, Castleman → autoimmune LAD pattern (Habermann 2002)
  • current_medsrequired
    medication • used at CONTEXT
    Phenytoin, allopurinol, hydralazine, isoniazid, sulfasalazine, lamotrigine, carbamazepine → drug-induced LAD / DRESS (RegiSCAR Kardaun 2013 PMID 23855313)
  • temperaturerequired
    vital • used at CONTEXT
    Fever + LAD pattern recognition (FUO criteria — Petersdorf)
  • cbc_with_diff_smearrequired
    lab • used at INITIAL_WORKUP
    Blasts → acute leukemia; atypical lymphocytes → mono (Cohen NEJM 2000 PMID 10944566); cytopenias → marrow infiltration (NCCN 2024)
  • ldhrequired
    lab • used at INITIAL_WORKUP
    Lymphoma marker; elevated correlates with bulk + IPI score (Lugano Cheson 2014)
  • uric_acid
    lab • used at INITIAL_WORKUP
    Tumor lysis risk if high-grade lymphoma / acute leukemia (NCCN 2024)
  • esr_crprequired
    lab • used at INITIAL_WORKUP
    Inflammation magnitude — Hodgkin IPS component (Engert NEJM 2010)
  • comprehensive_metabolic_panelrequired
    lab • used at INITIAL_WORKUP
    LFTs (DRESS pattern; hepatic infiltration); creatinine (renal infiltration); electrolytes (tumor lysis)
  • ebv_cmv_serologyrequired
    lab • used at INITIAL_WORKUP
    Mononucleosis common cause of cervical / generalised LAD (Cohen NEJM 2000 PMID 10944566); monospot if acute
  • hiv_4th_genrequired
    lab • used at INITIAL_WORKUP
    HIV-associated LAD common; primary HIV → generalised LAD + mononucleosis-like syndrome
  • rpr_or_treponemal
    lab • used at INITIAL_WORKUP
    Syphilis (secondary) — generalised LAD + rash (Habermann 2002)
  • tb_igra
    lab • used at INITIAL_WORKUP
    TB lymphadenitis — scrofula / mediastinal (Mohapatra 2009 PMID 20209720)
  • bartonella_serology
    lab • used at INITIAL_WORKUP
    Cat-scratch — IgG/IgM (Florin Klotz 2008 PMID 21243990)
  • ana
    lab • used at INITIAL_WORKUP
    SLE, autoimmune LAD differential (Habermann 2002)
  • hepatitis_panel
    lab • used at INITIAL_WORKUP
    Hep B/C reactivation risk before rituximab / chemo; chronic hep can cause LAD (NCCN 2024)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Mediastinal LAD (lymphoma, sarcoid, TB, met carcinoma) — first-line for hilar disease (Bazemore 2002)
  • cervical_ultrasound
    imaging • used at INITIAL_WORKUP
    Cervical LAD characterization — shape (round vs oval), hilum, vascularity (NCCN 2024)
  • ct_neck_chest_abd_pelvis
    imaging • used at BRANCHING_WORKUP
    Generalised LAD or large persistent — staging + biopsy targeting (Lugano Cheson 2014)
  • pet_ct_fdg
    imaging • used at BRANCHING_WORKUP
    Lymphoma staging + hot-spot guidance for biopsy + Lugano response (Cheson 2014 PMID 25113753)
  • excisional_biopsy_pathology
    lab • used at BRANCHING_WORKUP
    EXCISIONAL biopsy preferred over FNA for lymphoma (architecture + flow + cytogenetics + IHC); FNA inadequate (Lugano Cheson 2014; NCCN 2024)
  • flow_cytometry
    lab • used at BRANCHING_WORKUP
    B vs T vs NK clonality; aberrant marker patterns; rapid leukemia/lymphoma classification (NCCN 2024)
  • bone_marrow_biopsy
    lab • used at BRANCHING_WORKUP
    Staging lymphoma + leukemia confirmation if blasts / cytopenias (Lugano Cheson 2014)

12-phase flow (12)

  1. 1FRAME
    Confirm LAD vs lipoma / cyst / parotid / branchial / thyroid / hernia; localised vs generalised; localize by region (cervical / axillary / inguinal / supraclavicular / epitrochlear / mesenteric / hilar) (Bazemore 2002 PMID 12484692)
    inputs: node_location, node_distribution, node_size, consistency, tenderness
    advance: LAD confirmed + region + distribution + features defined
  2. 2ENTRY
    Palpable node, incidental imaging, B-symptoms + node, supraclavicular at any size, hilar / mediastinal, rapidly enlarging + cytopenia, drug-induced (Bazemore 2002; Lugano 2014; RegiSCAR 2013)
    inputs: age
    advance: Entry pattern recognized
  3. 3CONTEXT
    Duration, trajectory, B symptoms, pruritus + alcohol pain (Hodgkin), exposures (cat, livestock, travel, TB), drugs (DRESS quintet), sexual, IVDU, tattoo, autoimmune history (Habermann 2002; Cohen 2000; Florin 2008; RegiSCAR 2013)
    inputs: duration_trajectory, b_symptoms, travel_animal_sick_contacts, sexual_history, current_meds, temperature
    advance: Context complete + life-threat screen run
  4. 4RED_FLAGS
    Supraclavicular ANY size (Virchow), hard fixed painless, B symptoms + cytopenia (acute leukemia), rapid growth, generalised + organomegaly, mediastinal mass with airway / SVC compromise (pediatric — anesthesia-induction-risk), DRESS (drug + LAD + rash + eos + LFT rise + HHV-6 reactivation), tumor lysis at presentation (Bazemore 2002; Lugano 2014; RegiSCAR 2013)
    inputs: node_location, b_symptoms
    actions: workup.lymphadenopathy_biopsy
    advance: Acute red flags addressed
  5. 5INITIAL_WORKUP
    Stage-1: CBC + smear (blasts? atypical lymphs? cytopenias?), LDH, uric acid (TLS risk), CMP (LFTs / Cr), ESR/CRP, EBV/CMV serology + monospot (Cohen 2000), HIV 4th gen, RPR, TB IGRA (Mohapatra 2009), Bartonella serology if cat exposure (Florin 2008), ANA; CXR (Bazemore 2002)
    inputs: cbc_with_diff_smear, ldh, esr_crp, comprehensive_metabolic_panel, ebv_cmv_serology, hiv_4th_gen, cxr
    actions: panel.cbc, panel.inflammation, workup.lymphadenopathy
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    Stage-2 imaging — CT neck/chest/abd/pelvis if generalised / large persistent / hilar / mesenteric; PET-CT staging if lymphoma suspected (Lugano Cheson 2014); Stage-3 biopsy — EXCISIONAL preferred for lymphoma (FNA INADEQUATE except metastatic head-and-neck SCC or cystic), bone marrow biopsy if cytopenias / staging, flow cytometry (NCCN 2024)
    inputs: ct_neck_chest_abd_pelvis, pet_ct_fdg, excisional_biopsy_pathology
    actions: workup.lymphadenopathy_biopsy
    advance: Stage-2/3 imaging + biopsy as warranted
  7. 7DIFFERENTIAL
    Reactive / infectious (TB, HIV, EBV, CMV, toxo, Bartonella, syphilis, tularemia, brucellosis) / malignant (Hodgkin, non-Hodgkin, leukemia, metastatic carcinoma — Virchow gastric, Sister Mary Joseph intra-abd, Delphian thyroid, epitrochlear cat-scratch/lymphoma/syphilis) / autoimmune (SLE, RA, sarcoid, Castleman, IgG4) / drug-induced (DRESS quintet) / pediatric (Kawasaki, atypical mycobacterial)
    advance: Differential ranked with pre-test priors documented
  8. 8RISK_STRATIFICATION
    Post-biopsy Lugano staging (Cheson 2014 PMID 25113753 — supersedes Ann Arbor); IPI / FLIPI for NHL; IPS for Hodgkin (Engert NEJM 2010); ECOG PS — schema-blocked, surfaced in depth bundle
    advance: Risk score (post-diagnosis) documented
  9. 9TREATMENT
    Directed: cephalexin / clindamycin for bacterial cervical lymphadenitis; doxycycline / azithromycin for Bartonella (Florin 2008); RIPE for TB lymphadenitis (Mohapatra 2009); antivirals usually unnecessary for EBV; chemo-immunotherapy for lymphoma (onco); steroid AVOIDANCE until lymphoma excluded; stop offending drug + supportive + systemic steroid for DRESS (RegiSCAR 2013)
    advance: Targeted therapy plan documented
  10. 10DISPOSITION
    Outpatient 4-week observation if reactive features + <2 cm; expedited biopsy referral if suspicious; admit if airway compromise / tumor lysis / DRESS / cytopenia / severe B-sx (Bazemore 2002; NCCN 2024)
    advance: Disposition documented
  11. 11MONITORING
    Reactive — q2 wk reassessment with documented size + photographs; lymphoma — Lugano response criteria (PET Deauville 5-point + CT) (Cheson 2014); DRESS — LFT + CBC + eos resolution; TB — sputum / IGRA + clinical
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Heme-onc if lymphoma / leukemia; ID if TB / HIV / Bartonella; rheumatology if SLE / sarcoid; dermatology if DRESS; surgical onc if metastatic carcinoma (NCCN 2024)
    advance: Referrals scheduled