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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 • • • • • Prevalence Evaluation – History and examination Worrying features Suggested Management plans Short and easy quiz to highlight take home messages Introduction • • • • 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 • • • • • • • 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 • • • • • • • 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 – – – – – – – 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 • • • • 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 • • • • • • 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 ! • • • • • • • 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 • • • • • • • • Thyroglossal cyst Branchial cleft cyst Sternomastoid tumour Cervical rib Cystic hygroma Haemangioma Laryngocele Dermoid cyst Laboratory Investigations • • • • • • • • • • 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 – – – – – 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 • • • • • • • • • 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? • • • • • 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: • • • • • 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: • • • • • 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? • • • • • 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 • • • • • • • Lymphoma Thymoma Malignant germ cell tumour Benign teratoma Substernal goitre Thymic cyst Mesenchymal tumours Middle Mediastinal masses • • • • • • • Lumphoma Tuberculosis Sarcoidosis Histoplasmosis Bronchogenic cyst Castleman’s disease Sarcoma Posterior Mediastinal masses • • • • • • • • Neuroblastoma Ganglioneuroma Neurofibroma Primitive neuroectodermal tumour Sarcoma Germ cell tumour Duplication cyst Schwannoma