Chapter 6 Lymph and Immune System Conditions: Introduction

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Chapter 6Lymph and Immune System Conditions
Introduction

• Lymph system structure
• Lymph capillaries open-ended squamous cell
  tubules that absorb interstitial fluid (ISF)
• ISF becomes lymph when it moves into lymph
  capillary
• Capillaries carry lymph to nodes for cleaning,
  filtering
• Larger ducts carry cleaned lymph back to
  circulatory system, where it changes its name to
  plasma

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Lymph and Immune System Conditions Introduction,
cont.

• Lymph system function
• No pump what moves fluid?
• Gravity
• Muscle contraction
• Alternating hot and cold
• Breathing
• Massage
• Pétrissage, draining
• Manual lymph drainage, lymphatic facilitation
• Starlings equilibrium
• Most of what is squeezed out of circulatory
  capillaries gets back in the leftover (now
  called ISF) is approximately 10

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Lymph and Immune System Conditions Introduction,
cont.
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Lymph and Immune System Conditions Introduction,
cont.

• Immune system function (see animation)
• self vs. non-self eradicate or isolate
  non-self ASAP
• Nonspecific immunity agents behave the same,
  regardless of the antigen
• Neutrophils, monocytes, macrophages
• Intact skin, saliva, gastric juice, mucous
  membranes
• Specific immunity the ability to recognize and
  remember past infection
• T-cells, B-cells designed to fight specific
  organisms
• Antibodies and memory cells continue to circulate
  after initial exposure

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Lymph and Immune System Conditions Introduction,
cont.
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Lymph and Immune System Conditions Introduction,
cont.

• Hypersensitivity reactions (autoimmune diseases
  and allergies)
• Type 1 immediate, IgE (class of antibody)
  stimulates mast cells for histamine release
• Reactions stay local to site of exposure, but
  histamine may travel systemically, leading to
  anaphylaxis
• Hay fever, asthma, eczema, hives

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Lymph and Immune System Conditions Introduction,
cont.

• Type 2 cytotoxic reactions (rare)
• Mismatched blood, some autoimmune diseases
• Type 3 antibodies bind with antigens, form
  inflammatory triggers
• Lupus, glomerulonephritis, rheumatoid arthritis
• Type 4 delayed reaction
• Contact dermatitis, poison ivy, latex allergy,
  other skin allergies

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Edema

• Accumulation of excess fluid between cells
• Inflammation, poor circulation
• Not noticeable until 30 more fluid than normal
• Causes
• Mechanical (weak heart, obstruction)
• Chemical (inflammation, proteins in fluid)

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Edema, cont.
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Edema, cont.
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Edema, cont.

• Massage?
• Contraindicated edemas
• Heart, kidney failure
• Liver congestion
• Local infection
• Mechanical blockage (clot, pregnancy, removed
  lymph nodes)
• Indicated edemas
• Postacute musculoskeletal injury
• Immobilization (if blood clots are ruled out)
• Techniques specific for lymph flow, or that do
  not push fluid may be safe, depending on cause

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Lymphangitis

• Infection with inflammation of lymph capillaries
• Lymphadenitis infection of lymph nodes
• Occupational hazard for massage therapists
• Etiology
• Lymph capillaries become infected, usually with
  resident strep

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Lymphangitis, cont.

• Signs and symptoms
• Inflammation
• Scarlet track running proximally toward nearest
  lymph nodes
• Can become systemic swollen nodes, fever,
  malaise
• Complications
• If infection gets into bloodstream septicemia
  (blood poisoning)

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Lymphangitis, cont.
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Lymphangitis, cont.

• Treatment
• Antibioticsfast!
• Massage?
• Not during acute infection
• Best to wait until antibiotics are finished
• Do not let this happen to you!
• Good care of general health
• Good care of hands, open lesions

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Lymphoma

• Cancer of the lymph nodes
• Incidence
• 61,000 diagnoses/year
• 53,4000 non-Hodgkins lymphoma 23,400 deaths
• 7,600 Hodgkins 1,300 deaths
• Usually adults
• Non-Hodgkins most common 6070 years
• Hodgkins most common in 20s and over 50 years

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Lymphoma, cont.
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Lymphoma, cont.

• Etiology
• Originates with DNA mutation of T-cell, B-cell,
  natural killer cell in lymph nodes
• Replication of nonfunctioning lymphocytes
• Types of lymphoma
• Hodgkins lymphoma (approximately 10)
• Non-Hodgkins lymphoma (approximately 90)
• Low-grade
• Intermediate-grade
• High-grade
• (several types within each classification)

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Lymphoma, cont.

• Risk factors
• Statistical relationship to exposures
• Insecticides, herbicides, fertilizers, hair dyes
• Infection with some pathogens (HIV, Epstein-Barr,
  Helicobacter pylori, others)
• Signs and symptoms (present 2 weeks )
• Painless enlargement of lymph nodes
• Neck, axilla, inguinal area
• Anemia (overproduction of lymphocytes)
• Fatigue, weight loss, night sweats, itchy skin,
  loss of appetite
• Late stage depressed immunity

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Lymphoma, cont.

• Staging
• Staged by degree of progression, plus the
  presence of night sweats, fever, weight loss
  (this is a B form)
• Treatment
• Depends on what type of cell is affected whether
  it presents in A or B form
• Chemotherapy, radiation
• Also, bone marrow transplant, radioactive
  antibodies to destroy cancer cells

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Lymphoma, cont.

• Prognosis
• Slower-growing forms less responsive to treatment
• Overall 5-year survival rate is 56
• Children have better statistics 78
• 445,000 lymphoma survivors in the United States
• Massage?
• Rigorous circulatory massage is contraindicated
• Work with oncology team for best treatment
  tolerance

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Mononucleosis

• Viral infection of salivary glands and throat
• 90 is Epstein-Barr virus (EBV)
• 10 cytomegalovirus
• Both members of herpes family never fully
  expelled
• Incidence
• 90 of U.S. adults have been exposed to EBV
• Not all get mono
• 45100,000
• Mostly 1530 years old
• Up to 3 of college students every year

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Mononucleosis, cont.

• Etiology
• Spreads most efficiently through direct contact
• kissing disease
• Stage 1 attacks throat and salivary glands
• 60 days incubation (contagious, not symptomatic)
• Stage 2 attacks B-cells in lymph nodes, liver,
  spleen
• Makes B-cells look like monocytes, hence the name
• Takes a long time to quell this infection
• Later the virus may reactivate, be contagious,
  but asymptomatic

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Mononucleosis, cont.

• Signs and symptoms
• May vary widely
• Young people have more subtle infections
• Prodrome general fatigue, malaise
• Acute fever (102º104º) sore throat, swollen
  lymph nodes
• Maybe splenomegaly, hepatitis, rash (especially
  if taking penicillin-based antibiotics)
• Acute symptoms last 2 weeks may be months
  before fully functional

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Mononucleosis, cont.
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Mononucleosis, cont.

• Diagnosis
• Difficult to stage
• Looks like flu, rubella, acute phase of HIV/AIDS,
  measles, strep throat
• Complications
• CNS infection
• Strep throat
• Enlarged spleen (danger of rupture avoid contact
  sports)

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Mononucleosis, cont.

• Treatment
• Supportive therapy (rest, fluids, good nutrition)
• Massage?
• Not during acute stage
• In recovery, lymphatic congestion may be present
• Energetic work to support healing without taxing
  lymph/circulatory flow is most appropriate

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Allergic Reactions

• Immune system reactions against triggers that are
  not inherently harmful
• Incidence
• 50 million/year
• 18 billion/year to treat

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Allergic Reactions, cont.

• Etiology
• Antibodies may attach to non-dangerous antigens
  (pollen, etc), causing an inflammatory response
• Two versions of hypersensitivity reactions can be
  especially extreme
• Anaphylaxis
• Angioedema

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Allergic Reactions, cont.
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Allergic Reactions, cont.
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Allergic Reactions, cont.

• Anaphylaxis
• Severe systemic reaction massive histamine
  release systemic vasodilation, risk of edema
  that can block airways, circulatory shock
• 1st exposure may not create extreme reactions
  subsequent exposures get progressively worse
• Triggers
• Antibiotics (penicillin) latex insect stings
  blood products, eggs, fish, shellfish

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Allergic Reactions, cont.

• Angioedema
• Rapid onset of localized swelling
• Skin, genitals, extremities, GI tract,
  respiratory tract (can obstruct airway)
• Triggers
• Nuts, chocolate, fish, berries, eggs, milk,
  preservatives, aspirin, ACE inhibitors, some
  hypertensive drugs

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Allergic Reactions, cont.

• Signs and symptoms
• Anaphylaxis
• Hives, flushing, respiratory distress if in GI
  tract, nausea, vomiting, diarrhea, cramps,
  bloating ultimately, hypotension, fainting,
  shock
• Angioedema
• Depends on location
• Usually asymmetric, may not be itchy, usually
  resolves within 72 hours

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Allergic Reactions, cont.
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Allergic Reactions, cont.

• Treatment
• Benadryl in short-term
• Steroidal anti-inflammatories after crisis
• Long-term desensitization sometimes used
• Massage?
• Not while in acute reaction
• Get information on allergens use hypoallergenic
  lubricant if necessary

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Chronic Fatigue Syndrome

• Collection of signs and symptoms that center on
  debilitating fatigue
• Also called
• Chronic fatigue and immune dysfunction syndrome
  (CFIDS)
• European version may be what they call myalgic
  encephalomyelitis
• Incidence
• Difficult to determine not all seek treatment
• 500,000800,000 in the United States?
• Not diagnosed in children

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Chronic Fatigue Syndrome, cont.

• Causes
• Not well understood multifactorial
• History of pathogenic exposure (EBV, candidiasis,
  mycoplasmas?)
• Anomalies in immune system function

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Chronic Fatigue Syndrome, cont.

• Two CNS dysfunctions are somewhat consistent
• Hypothalamus-pituitary-adrenal axis dysfunction
• Sluggish, tenacious stress responses, adrenal
  depletion
• Neurally mediated hypotension
• Poor response to adrenaline difficulty
  maintaining blood pressure

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Chronic Fatigue Syndrome, cont.

• Signs and symptoms
• Fatigue, unrelieved by rest
• General muscle/joint pain
• Low-grade fever, swollen lymph nodes
• Short-term memory loss, poor concentration
• Bloating, nausea, diarrhea
• Many, many others!
• Huge overlap with
• Fibromyalgia
• Irritable bowel syndrome

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Chronic Fatigue Syndrome, cont.
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Chronic Fatigue Syndrome, cont.

• Diagnosis
• Rule out anything else (long list!)
• Specific criteria
• Unexplained fatigue in a new pattern
• At least 4 of the following, for 6 months

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Chronic Fatigue Syndrome, cont.

• Treatment
• Modify life to support good health
• Manage stressors, avoid stimulants, careful
  exercise
• Possibly look for nutritional deficiencies
• Medication
• Immune-suppressants and low-dose antidepressants
• Massage?
• Can be key in movement toward better self-care
• Improves quality of sleep
• Improves recovery after exercise, muscle and
  joint pain

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Fever

• Abnormally high body temperature
• Indicates infection, tissue damage
• Steps in progression
• Infection occurs
• WBCs eat invaders
• Interleukin-1 is secreted
• Interleukin-1 stimulates hypothalamus to reset
  the thermostat
• Muscles and glands work to raise core temperature

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Fever, cont.
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Fever, cont.

• When target temperature has been reached
  (crisis), cooling mechanisms take over
• Sweating, vasodilation
• Fever is usually a good sign!
• Cytokines stimulate immune system activity
• Interferon (antiviral agent) is more active
• Iron from liver and spleen is limited slows down
  pathogens
• Raises heart rate, speeds circulation of immune
  system agents
• Increases cell permeability, more efficient
  chemical reactions

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Fever, cont.

• Complications
• Can get too high 104 (dehydration, acidosis,
  brain damage)
• Death at 112114
• Too quickly reduced can go to shock (systemic
  vasodilation)
• Massage?
• Contraindicated while acute
• Body is busy! massage therapist at risk if
  contagious disease is present
• Noncirculatory techniques may be appropriate to
  help get through crisis

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HIV/AIDS

• Viral attack on immune system cells
• Human immunodeficiency virus acquired immune
  deficiency syndrome
• Incidence, worldwide
• 40 million HIV
• 2.5 million are younger than 15 years
• 5 million new infections per year
• 14,000 per day
• 80 of infections worldwide are the result of
  heterosexual intercourse

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HIV/AIDS, cont.

• Incidence, United States
• 886,000 are known to be HIV thousands more do
  not know
• 40,000 new infections each year
• ½ of new infections are in people younger than 25
  years
• 10,000 children under 13 are HIV
• 60 of males through homosexual intercourse 15
  through heterosexual intercourse
• 75 of women through heterosexual intercourse
• 25 of new infections for men and women from
  shared needles

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HIV/AIDS, cont.

• Etiology
• Virus enters the body through shared fluids
• Blood, semen, vaginal secretions, breast milk
• Virus targets nonspecific WBCs, gets carried to
  lymph nodes
• Then virus targets helper T-cells
• Portal of entry CD4
• Without helper T-cells, immune response is
  crippled

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HIV/AIDS, cont.

• Virus invades active and inactive T-cells
• Becomes virulent when dormant T-cell is activated
• Virus can spread with different mechanisms
• Core of lymph nodes, CNS cells
• Virus is vulnerable during conversion of RNA to
  DNAthis is where medications work to slow
  progression

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HIV/AIDS, cont.

• Progression
• Phase 1 New infection no immune response, but
  viral load is growing and communicability is
  high Can last 6 months
• Phase 2 Acute primary infection an immune
  response develops, looks like flu or mono, 2
  weeks
• Phase 3 Asymptomatic stagevirus continues to
  invade, immune system keeps up medication works
  to prolong
• Phase 4,5 AIDSdiagnosed with T cell count drops
  

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HIV/AIDS, cont.

• Resistance variables
• Host resistance genetic mutation for fewer CD4
  sites
• Immune system response HIV can inhibit cellular
  display of infection this may be a target for
  treatment
• Virulence of virus some strains are stronger
  than others may be weakened by medication, other
  factors
• Any combination of these factors

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HIV/AIDS, cont.

• Complications (indicator diseases)
• Pneumocystis carinii pneumonia (PCP) a fungal
  infection of the lungs
• Cytomegalovirus (a herpes virus) can infect the
  eye, colon, lung, or adrenal glands
• Kaposis sarcoma, a type of skin cancer
• Non-Hodgkins lymphoma
• Others
• Thrush, herpes simplex, shingles, peripheral
  neuritis, cervical cancer, meningitis,
  tuberculosis, hepatitis some of these are
  communicable to healthy people through casual
  contact

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HIV/AIDS, cont.

• Diagnosis
• May take 6 months for antibodies to be present in
  a blood test
• Treatment
• HAART highly active antiretroviral therapy
• Works to elongate the asymptomatic period
• Still cannot access virus in dormant T-cells
• Costs 15-20 thousand per year

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HIV/AIDS, cont.

• Massage?
• If client is HIV and asymptomatic, massage is
  safe and appropriate
• If client is in end-stage AIDS, massage may be a
  comfort measure
• Risks
• Therapist could bring pathogens to a vulnerable
  client
• Client could have pathogens (TB, herpes, etc.)
  that could spread to therapist
• Therapist could overwhelm a client whose system
  is delicate
• Benefits
• Massage strengthens immune system response
  excellent coping mechanism
• Nonjudgmental touch for an ostracized segment of
  society

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Inflammation

• Tissue response to injury or potential invasion
• Three main components
• Chemical
• Histamine, cytokines
• Vascular
• Vasoconstriction/vasodilation
• Cellular
• WBC, platelets

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Inflammation, cont.
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Inflammation, cont.

• Progression
• 1. Acute vascular response
• Vasoconstriction, followed by vasodilation
• 2. Immediate cellular response
• Neutrophils arrive first
• Followed by antibodies, platelets, clotting
  factors
• Blood clots are woven

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Inflammation, cont.

• 3. Long-term cellular response
• Macrophages, lymphocytes
• Clean-up crew
• Pus forms (tissue exudate)
• Fibroblasts
• Produce delicate form of collagen to begin scar
  tissue
• 4. Resolution and maturation
• Blood clots dissolved
• Scar tissue becomes denser, aligns according to
  weight-bearing stress

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Inflammation, cont.

• Steps 12 are acute phases (13 days, depending
  on severity of injury)
• Step 3 is post-acute, can last 2 weeks
• Step 4 can last months or years, depending on the
  quality of the healing

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Inflammation, cont.

• Signs and symptoms
• Pain, heat, redness, swelling
• Dolor, calor, rubor, tumor
• Can also include
• Loss of function (especially at joints)
• Pus
• Itching
• Clotting

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Inflammation, cont.

• Treatment
• RICE
• Anti-inflammatories
• NSAIDs, Cox-2 inhibitors
• Steroids
• Massage?
• At least local contraindication during acute
  phase
• (some lymph movement techniques may be safe if
  practitioner is knowledgeable)
• Clients taking anti-inflammatories or painkillers
  are vulnerable to overtreatment be conservative!

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Lupus

• Autoimmune attack on a variety of different
  tissues
• Incidence
• 1.42 million in the United States 4050100,000
• 16,000 diagnoses/year
• African-Americans and Asians more than Caucasians
• Women men, 91

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Lupus, cont.

• Three types
• Drug-induced
• Related to some medications symptoms resolve
  when medication is stopped
• Discoid lupus erythematosus
• Affects skin only
• Small scaly patches
• Malar rash
• May go on to develop SLE
• Systemic lupus erythematosus (SLE)
• Antibody attacks in various areas lead to
• Arthritis, renal failure, thrombosis, CNS
  problems, pericarditis, pleurisy

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Lupus, cont.

• Causes of SLE
• Unknown
• Genetic link slightly elevated risk within
  families
• Environmental factors
• Viral exposure
• UV light
• Some medications
• High estrogen
• Immune system anomalies

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Lupus, cont.

• Signs and symptoms (by body system)
• Skin malar or discoid rash (source of name
  lupus, wolf), hives, other signs
• Exacerbated by sunlight
• Musculoskeletal system
• 8090 develop arthritis hand, feet more than
  spine
• May have symptoms of fibromyalgia
• Nervous system
• 25 have headaches, fever, seizure, psychosis
• Can increase risk of stroke

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Lupus, cont.
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Lupus, cont.

• Cardiovascular system
• Inflammation of blood vessels, atherosclerosis
  and associated disorders
• Damage at pericardium
• Anemia
• Raynauds phenomenon
• Respiratory system
• Pleurisy

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Lupus, cont.

• Urinary system
• 50 develop glomerulonephritis risk of renal
  failure
• Reproductive system
• Clotting disorder causes miscarriage
• Medications to control incompatible with
  pregnancy

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Lupus, cont.

• Diagnosis
• 4 of 11 signs and symptoms (not necessarily
  simultaneously)

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Lupus, cont.

• Treatment
• NSAIDs, steroids, anti-malarial drugs, cytotoxic
  drugs
• Other treatments for symptomatic relief
• Usually manageable 8090 have normal lifespan
• Massage?
• Avoid circulatory massage during flares
• during remission, be guided by health and
  resilience of client
• Get information on cardiovascular, kidney health
• Most patients have arthritis
• Can improve quality of life, if not course of
  disease

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FIN