Download Lymphadenopathy in Children

Lymphadenopathy in children
Dr.A.Kundu
Consultant Paediatrician
QMHC
Objectives
• Identify common causes of acute and
chronic lymphadenopathy in children
• Describe the management of cervical
lymphadenopathy in children
• Look at a suggested algorithm for
management of this common problem
Outline of talk
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Prevalence
Evaluation – History and examination
Worrying features
Suggested Management plans
Short and easy quiz to highlight take
home messages
Introduction
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Not uncommon
Majority benign, self-limited
Some may be serious
Parents find lump
– ?Cancer
– ?Specific Diagnosis
• Role of primary carer
– Evaluate, Explain and Treat appropriately
Lymph node regions
Question
• When are these lumps significant ?
• When does one need to worry ?
• Differential diagnosis - crucial
Lymph nodes in healthy
children
• Prevalence
• Bamji etal :
Neonates: 34% palpable lymph nodes
Infancy : 57% (cervical – 41%)
Size 0.3-1.2cm in NB & 1.6cm in infants
• Herzog et al : 3/52 to 6 yrs
45 % healthy children had palpable
nodes
Cervical lymphadenopathy
• Upto 90% children between 4-8yrs may
have palpable cervical nodes without
systemic or regional disease
• Incidence of D/D
– Reactive 32-64%
– Tubercular 23-40%
– Lymphomatous 7-13%
(Torsiglieri 1988;Connolly 1997; Smith 2000)
Causes of Lymphadenopathy
• Proliferation of lymphocytes in the
nodes
– Infection
– Lymphoproliferative disorder
– Infiltration by inflammatory cells/ malignant
– INFECTION IS THE COMMONEST
TRIGGER
Evaluation of
lymphadenopathy
• History
– Presence / exposure to infections
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URTI
Dental
Skin
Insect bites
Pet scratches
Infectious mononucleosis
Tuberculosis
History
• Acute vs Chronic
• Localised (3/4) vs
Generalised (1/4)
– Only 17% of
generalized
Lymphadenopathy
identified
• Unilateral vs
Bilateral
History
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Onset
Duration
Rate of growth
Systemic symptoms
Recent Illness
Contact with Cats,TB
Prior treatment if any
History
• International travel
• Medications
• Document presence/ absence of Systemic
symptoms
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Fever
Weight loss
Fatigue
Rash
Arthralgia
Chronic cough
Night sweats
Summary points from History
• Onset ,Duration and progression
• Preceding upper respiratory tract
infections
• Any lumps outside the head & neck
region
• Travel abroad or Contact with
Tuberculosis
• Contact with cats
Physical Examination
• Record Temperature
• Plot weight and Height on Growth chart
• Palpate nodes – document
– Size ( >2 cm & no ENT cause), TB,CSD,
malignancy
– Location: Supraclavicular – mediastinal disease
– Nos;Consistency;mobility;tenderness;matting
– Lymph nodes in other regions- same information
– Skin:
Eczema,Impetigo,rashes,Seborrhea,Petechiae
– Eyes
– Ear ,Nose, Throat and oral cavity
• Abdomen : Look for Hepatosplenomegaly
Types of lymphadenopathy
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Acute Infective lymphadenitis
Acute Reactive lymphadenitis
Chronic lymphadenopathy
Recurrent infections &
lymphadenopathy
Acute Infective lymphadenitis
• Unilateral
• Infection in the node
• Febrile, Tender,
Erythematous, Fluctuant
• Staphylococcus or Grp.A.Streptococcus
• Peptostreptococcus,Gram neg rods,
Acute Reactive lymphadenitis
• Relatively simple to diagnose and treat
• Infection in the region
– ENT, URTI
– EBV,CMV
– Kawasaki disease
Chronic lymphadenopathy
• Majority of children with persistently enlarged
node – no cause is found
• If cause found
– Granulomatous
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Atypical Mycobacteria
Bartonella Hensellae
Tuberculosis
Toxoplasmosis
Malignancy
Rarely, Sarcoid etc
Generalised Lymphadenopathy
Causes
• Systemic infections:
Bact/Viral/Fungal/parasitic
• Autoimmune:JCA/SLE/Hemolytic anemia
• Primary lymphoid Neoplasm
• Metastatic Neoplasm
• Storage disease:Gaucher’s/Niemann-Pick
• Drugs:Phenytoin/INH
Regional Adenopathy
Worrying features !
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Rapid and progressive growth
Hard/fixed nodes
Pallor/bruising/purpura
Hepatosplenomegaly
Skin ulceration
Ill child/ Wt. loss/ Lethargy/ Loss of appetite
Mass larger than 3 cm with firm or hard
consistency
• Family h/o TB/Lymphoma
Cervical Lymphadenopathy
Causes
• Infection
– Viral: Respiratory viruses/EBV/CMV/Rubella
– Bacterial:Staph/Strep/Anaerobes/CSD/TB
– Protozoal: Toxoplasmosis
• Malignancies:
– Neuroblastoma/Leukemia/Lymphoma/Rhabdo
• Miscellaneous:
– Kawasaki/Collagen/Serum sickness/Post
vaccination/Rosai-Dorfman/Kikuchi- fujimoto
Cervical lymphadenopathy
Age
– NewbornStaphylococcus/Grp
B strep
– < 5 years –
Staphylococcus
aureus
– School age –
Viral/Cat
scratch/Atypical
Myco/Mycobacteria/
Toxoplasmosis
D/D Cervical
Lymphadenopathy
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Thyroglossal cyst
Branchial cleft cyst
Sternomastoid tumour
Cervical rib
Cystic hygroma
Haemangioma
Laryngocele
Dermoid cyst
Laboratory Investigations
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FBC and Differential including Film
ESR
LDH and Uric acid
LFT
Chest X ray
Mantoux
Cat scratch serology / Toxoplasma serology
Monospot / EBV serology
Ultrasound
Biopsy
Management
• Acute bilateral cervical lymphadenitis
– Infection with respiratory viruses
commonest
– Conservative management
– If systemic illness suspected ie.Febrile, Ill
appearance
• FBC,Film,Cultures,LFT Serology
EBV,CMV,Toxo
Management
• Acute pyogenic cervical lymphadenitis
– 80% by Staphylococal/Streptococcus
– Upto 6cm in size
– High Fever/ Toxic/cellulitis/abscess
Hospitalisation ?USS
– Dental/periodontal disease- Anaerobic
organisms
– Well appearing – no evidence of abscess
• Therapeutic trial of oral antibiotic appropriate
• 10 % of these will require Incision &Drainage
Management
• Chronic cervical Lymphadenopathy
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School age children
EBV,CMV
Non tuberculous mycobacterial infection
Cat Scratch disease
Toxoplasmosis( Consider in those Infectious
mononucleosis suspected but negative tests)
– Mantoux
– Excision biopsy may be needed
Recurrent infections &
lymphadenopathy
• Consider
– Chronic granulomatous disease
– Leucocyte adhesion deficiency disorder
– Hyper Immunoglobulin E disorder
– HIV
Features prompting ?Biopsy
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Size >2 cm ( No obvious cause)
Increasing size over 2 weeks
No decrease over 4-6 weeks
Not return to baseline in 8-12 weeks
No change despite course of antibiotic
Abnormal Chest X ray
Supraclavicular node
Rubbery consistency
Systemic symptoms:
Fever/Wt.Loss/Arthralgia/Hepatosplenomegaly
Key points
• Antibiotics may be prescribed for lumps
of short duration as inflammatory
causes are common
• Refer the following
– Node for >6 weeks duration & getting
larger
– Node for <6 weeks duration but > 3 cm
– If TB suspected
– Non infectious Dominant node >6 weeks
Key points
• Single enlarging nodes more worrying than
multiple small nodes
• Soft, non progressive, mobile Chronic
lymphadenopathy is quite common
• Eczema can cause widespread
lymphadenopathy
• Normal FBC does not exclude lymphoma
• Look for wt.loss/anorexia/pain/systemic
features
Any Questions?
3 yr old with neck mass for 4 days with a temp of
40deg.
Unilateral, tender, 2 by 2 cm antr cervical lymphnode
with erythema but no fluctuation.Non toxic eating well.
Your best management plan is:
• Admit her to hospital for IV Flucloxacillin
• Consider Excisional biopsy
• Perform Needle aspiration for Gram stain &
Culture
• 10 day course of oral cephalexin to return if
no improvement
• Reassure mother that this is Glandular fever
and will resolve without therapy
3 month old baby cervical
lymphadenopathy,fever and poor
feeding.Smooth,fluctuant,mobile lymphnode in
antr triangle.
Rest of the examination is normal.
What is the most likely aetiologic agent?
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Adenovirus
Epstein-Barr virus
Human Immunodeficiency virus
Staphylococcus aureus
Streptococcus agalactiae
8 yr old boy with left sided neck mass enlarged for the
past 4 weeks. No wt loss/fatigue but has occasional
fever.Grandmother has kitten but denies any
scratches.Exam reveals unilateral slightly tender 3 by
3cm antr cervical node with no erythema.Mild bilateral
conjunctival injection. Rest exam normal. Most likely
cause for lymphadenopathy is:
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Cat scratch disease
Kawasaki disease
Chronic HIV infection
Malignancy
Staphylococcus aureus
10 year old girl 2 month h/o unilateral
lymphnode enlargement.No h/o wt
loss/fever/animal exposure.
Exam reveals 2 by 2 cm nontender lymphnode
with violaceous discoloration.
Most appropriate next step:
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Begin therapy with oral erythromycin
Consult surgery for excision
Obtain EBV titres
Perform Needle aspiration
Mantoux test and begin anti-mycobacterial
therapy if results are positive
Presence of lymphadenopathy in which of the
following areas most likely suggest s
malignancy as the etiology?
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Anterior Cervical
Posterior cervical
Preauricular region
Submandibular region
Supraclavicular region
References
• Lymphadenopathy-Textbook of Paediatric
Emergency medicine 2000;Chapter44
• Pediatric Clinics of North America 2002
• Lymphadenopathy in children:Clinical
Pediatrics; Feb 2004
• Cervical lymphadenopathy in
children;Hospital Medicine Feb 2003
• Pediatrics in review:Dec 2000
• Childhood cervical lymphadenopathy; Journal
of Pediatric health care;Feb 2004
Mediastinal masses
• Majority in children – malignant
• Cough, dyspnoea, Chest pain –
symptoms
• Orthopnea/dysphagia/SVC Syndrome/
• CT investigation of choice
Anterior Mediastinal masses
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Lymphoma
Thymoma
Malignant germ cell tumour
Benign teratoma
Substernal goitre
Thymic cyst
Mesenchymal tumours
Middle Mediastinal masses
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Lumphoma
Tuberculosis
Sarcoidosis
Histoplasmosis
Bronchogenic cyst
Castleman’s disease
Sarcoma
Posterior Mediastinal masses
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Neuroblastoma
Ganglioneuroma
Neurofibroma
Primitive neuroectodermal tumour
Sarcoma
Germ cell tumour
Duplication cyst
Schwannoma