Download 2010 Approach to Lymphadenopathy in Children U P D A T E

2010
U P D AT E
Pediatric, Adolescent Surgical Associates, P.C.
w w w. p a s a p c . c o m
S P R I N G
Approach to Lymphadenopathy in Children
What the pediatrician needs to know
Overview The cause of lymphadenopathy often is obvious after a complete
history and physical examination. Important aspects of the history and examination
include symptoms and signs suggestive of infection and/or systemic disease, and
the location, size, consistency, fixation, and tenderness of the lymph nodes.
Diagnostic Approach The diagnostic approach to children with peripheral
lymphadenopathy varies from observation and reassurance to comprehensive
diagnostic testing and aggressive medical and surgical therapy, depending upon
the findings from the history and physical examination. It is not necessary to
identify the underlying etiology in every patient since most cases are benign and
self-limited. The pace of the evaluation is dictated by how ill the patient appears.
Laboratory testing can be used to confirm a diagnosis that is suspected on the basis
of the history and physical examination (eg, throat culture for group A streptococcal
pharyngitis, heterophile antibodies for Epstein-Barr virus mononucleosis, serology
for Bartonella henselae for cat scratch disease). In more difficult cases, or in cases
in which the lymphadenopathy remains unexplained after the initial history,
examination, and laboratory tests, additional laboratory tests and lymph node
biopsy may be necessary.
In ALL cases, treatment with corticosteroids must be avoided before a definitive
diagnosis is made. Such treatment could mask or delay the histologic diagnosis of
leukemia or lymphoma.
History The history in a patient with lymphadenopathy should
focus upon the following:
• Location, duration, and laterality of adenopathy
• Local symptoms suggestive of infection (eg, cough, pharyngitis, dental
problems) or malignancy (eg, Horner syndrome, opsoclonus-myoclonus)
• Associated constitutional symptoms (fever, weight loss, night sweats,
arthralgias, skin rash) may suggest malignancy. Mycobacterium
tuberculosis (TB), or rheumatologic disease. Fever typically accompanies
lymphadenopathy caused by infections and is not particularly helpful
in discriminating between infectious and noninfectious causes of
lymphadenopathy.
• Contacts (viral respiratory infections, cytomegalovirus [CMV], Epstein-Barr virus
[EBV], group A streptococcal infection [GAS, Streptococcus pyogenes], TB)
• Dental problems or mouth sores
• Skin lesions or trauma (Staphylococcus aureus, GAS, herpes simplex virus,
cat scratch disease
• Animal exposures (cat scratch disease, toxoplasmosis [cats]
PASA Surgical Staff
General examination A complete physical examination
should be performed to look for signs of systemic disease or
infection: (eg, ecchymoses, rash, pharyngitis)
• Weight loss of >10 percent of body weight may be indicative of
malignancy.
• Scalp lesions, conjunctival injection, nasal obstruction
• Dental problems, pharyngitis, herpangina, herpes simplex virus
gingivostomatitis.
• Hepatosplenomegaly (systemic process such as EBV, CMV, HIV, syphilis,
neoplastic disease, rheumatologic disease); abdominal mass (eg,
neuroblastoma).
• Localized lesions; generalized rash (viral illness).
The lymph nodes should be examined with the following characteristics in mind:
Location Localized lymphadenopathy (present in only one region) suggests
local causes and should prompt a search for pathology in the area of node drainage
although some systemic diseases, such as lymphomas, can present with local
adenopathy.
Generalized adenopathy (present in two or more non-contiguous regions) usually
is a manifestation of systemic disease. Palpation of inguinal, cervical, and axillary
nodes, in addition to the liver and spleen, can determine whether lymphadenopathy
is localized or generalized.
Size Abnormal nodes generally are greater than 2.5 cm in diameter. Although
malignancy can be found in smaller nodes, it is more likely to be found in nodes
larger than 2 cm
Consistency Hard nodes are found in cancers that induce fibrosis and
when previous inflammation has left fibrosis. Firm, rubbery nodes are found in
lymphomas and chronic leukemia.
Fixation Normal lymph nodes are freely movable in the subcutaneous space.
Abnormal nodes can become fixed to adjacent tissues by invading cancers or
inflammation in tissue surrounding the nodes. They also can become fixed to each
other (“matted”) by the same processes.
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Tenderness Tenderness suggests that recent, rapid enlargement has caused
tension in the pain receptors in the capsule. Tenderness typically occurs with
inflammatory processes.
The ancillary evaluation for patients with peripheral adenopathy may include blood
tests, cultures, imaging, a trial of antimicrobial therapy, incision and drainage,
and/or lymph node biopsy. The sequence of the evaluation varies depending upon
whether the lymphadenopathy is localized or generalized and the presence of
associated symptoms.
Blood tests that may be necessary in the evaluation of a child with lymphadenopathy
include Complete blood count (CBC), Erythrocyte sedimentation rate (ESR),
Serology for EBV, Bartonella henselae, among others.
Leukopenia and the presence of atypical lymphocytes are important findings as
they may suggest an etiology (eg, malignancy, autoimmune lymphoproliferative
disease, EBV). Although the ESR does not help to differentiate infection from
malignancy, it tends to be higher (eg, ≥50 mm/hr) in patients with Hodgkin’s
lymphoma.
Cultures of the throat, skin, blood, and/or lymph node may be indicated in selected
circumstances:
Excisional biopsy (if tuberculous or nontuberculous mycobacterial infection is
strongly suspected) or incision and drainage may be indicated in the moderately or
severely ill child with acute unilateral lymphadenitis.
Tuberculin skin testing (TST) may be indicated to exclude M. tuberculosis infection.
TST also may result in reactive induration in children with nontuberculous
mycobacterial (NTM) infection, but TST is not sensitive for NTM disease.
Chest radiographs (CXR) may be necessary in the evaluation of the child with
peripheral lymphadenopathy. CXR are performed to look for mediastinal masses
or hilar adenopathy.
Although persistent lymph node enlargement prompts clinicians to obtain a biopsy,
as few as 20 percent of biopsies demonstrate a treatable disease. In some reported
series, the character or size of the nodes is helpful in deciding when a biopsy is
indicated, but location is probably the most important factor.
Early lymph node biopsy may be indicated in patients with the
following clinical features:
• Systemic symptoms include fever >1 week, night sweats, weight loss (>10
percent of body weight)
• Supraclavicular and lower cervical nodes
• Fixed, nontender nodes in the absence of other symptoms
• Abnormal CXR or CBC
• Lack of infectious symptoms
Numerous reviews have suggested approaches to the diagnosis of lymphadenopathy.
One model was able to predict the need for biopsy in 97% of young patients (ages
9 to 25 years) based upon three variables: abnormal CXR, lymph node size greater
than 2 cm and lack of ear, nose, and throat symptoms. Another surgical review
demonstrated significant correlations between adenopathy and malignancy when
patients were 10 years or older, had nodes greater than 3 cm, supraclavicular or
fixed nodes, or an abnormal CXR.
Localized nodes — The evaluation of children with localized adenopathy depends
upon the location and size of the nodes
Supraclavicular — Children with supraclavicular adenopathy should always be
evaluated with CBC, CXR, and biopsy.
Axillary — The evaluation of axillary adenopathy depends upon the size of the
nodes.
In children with small axillary adenopathy (<2.5 cm), bacterial (especially B.
henselae) and fungal cultures may be obtained and empiric therapy initiated as
indicated by the history and examination. Biopsy is indicated for those who fail to
respond to appropriate antimicrobial therapy or whose lymphadenopathy persists
for >1 month without improvement.
Large axillary adenopathy (≥2.5 cm) usually requires biopsy.
Cervical or inguinal — Patients with localized lymphadenopathy at other sites (eg,
cervical, inguinal), can be observed for three to four weeks and treated empirically
with antibiotics when appropriate, provided that nothing else in the history and
physical examination suggests malignancy (eg, weight loss >10 percent of body
weight, abnormal CBC or CXR, elevated ESR, fever, and lack of upper respiratory
tract infection symptoms).
The empiric antibiotic therapy should include coverage for common pathogens
such as group A streptococcus and Staphylococcus aureus; the choice is complicated
by the increasing prevalence of community-associated methicillin S. aureus
(CA-MRSA) and clindamycin or TMP-SMX as initial treatment is reasonable.
Antimicrobial therapy is usually continued for 10 to 14 days.
This approach is safe and avoids unnecessary biopsies; in many patients, the
adenopathy will resolve or the cause will become obvious during the two weeks
of observation, with or without therapy. Even with diagnoses such as Hodgkin’s
lymphoma, non-Hodgkin lymphoma, or tuberculosis, the window of opportunity for
effective treatment is likely to remain open during this brief period of observation.
Biopsy is appropriate if an abnormal node has not resolved after four weeks, or
immediately in patients with other findings suggestive of malignancy, including
weight loss (>10 percent of body weight), abnormal CBC or CXR, fevers, and lack
of upper respiratory tract infection symptoms.
To learn more details about lymphadenopathy in children or to discuss a specific
patient for possible referral, please contact Pediatric, Adolescent Surgical Associates,
P.C. at 404.252.3353.
To view the evaluation and treatment algorithms for lymphadenopathy, view the clinical
articles on our website at www.pasapc.com and click on Newsletters in the right menu bar.