lymphadenopathy

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Approach to lymphadenopathy in children: 

Approach to lymphadenopathy in children 1/3/2012 1

Introduction : 

Introduction Lymphadenopathy is a common complaint & physical finding in children, the size of L.Ns. rapidly increase during the first 12 years of the child's life to such an extent that the total L.N. mass will be twice the size of that seen in an adult. The size of nodes in children vary markedly because the child is continuously exposed to new viruses and bacteria. Thus, the challenge for the general pediatrician is to learn how to distinguish pathologic from nonpathologic lymph nodes and to develop a rational approach to the evaluation of lymphadenopathy. 1/3/2012 2

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Normal lymph nodes are discrete, non tender, and mobile without fixation to underlying tissues. Most children have palpable, small cervical, axillary , and inguinal nodes, but adenopathy in posterior auricular, epitrochlear , or supraclavicular area is definitely abnormal. Bamji et al. (1986) reported that normal lymph nodes have diameter of 3–12 mm in neonatal period and 3–16 mm in infants up to 1 yr of age. 1/3/2012 3

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Barness (1998) noted that cervical and inguinal lymph nodes up to 1 cm in diameter are normal in children up to 12 yrs of age. Because of its association with malignancy, lymphadenopathy can be a major source of parental anxiety. Lymphadenopathy refers to nodes that are abnormal in either size, consistency or number. There are various classifications of lymphadenopathy, but a simple and clinically useful system is to classify lymphadenopathy as “generalized” if lymph nodes are enlarged in two or more noncontiguous areas or “localized” if only one area is involved. 1/3/2012 4

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In general, lymph nodes greater than 1 cm in diameter are considered to be abnormal, exception are epitrochlear nodes, for which 0.5cm is considered abnormal & inguinal nodes, which are not considered abnormal unless they are > 1.5cm. 1/3/2012 5

Presentation of lymphadenopathy by anatomic site (in percentages) : 

Presentation of lymphadenopathy by anatomic site (in percentages) 1/3/2012 6

Diagnostic Approach to Lymphadenopathy: 

Diagnostic Approach to Lymphadenopathy 1/3/2012 7

History: 

History The physician should consider four key points when taking a patient's history: First , are there localizing symptoms or signs to suggest infection or neoplasm in a specific site? Second , are there constitutional symptoms such as fever, weight loss, fatigue or night sweats to suggest disorders such as tuberculosis, lymphoma, collagen vascular diseases, unrecognized infection or malignancy? 1/3/2012 8

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Third, are there epidemiologic clues, recent travel that suggest specific disorders? Fourth, is the patient taking a medication that may cause lymphadenopathy? Some medications are known to specifically cause lymphadenopathy (e.g., phenytoin [Dilantin]), while others, such as cephalosporins, penicillins or sulfonamides, are more likely to cause a serum sickness-like syndrome with fever, arthralgias , HSM and rash in addition to lymphadenopathy . 1/3/2012 9

Physical Examination : 

Physical Examination Always perform a complete physical exam beginning with general appearance, vital signs and growth parameters.  Are they febrile? Plot them on the appropriate growth chart; have they lost weight? Then perform a complete systematic physical exam paying special attention to head and neck, abdominal and dermatological examinations. Always pay special attention to the area of the enlarged node for a focus of infection. For example, in a child with cervical adenopathy one should examine the orpharynx and consider the possibility of streptococcal pharyngitis or viral upper respiratory infection.  Ask if the patient has had a sore throat or ear pain.  In an infant with occipital lymphadenopathy, one should examine the scalp for lesions such as seborrheic dermatitis. 1/3/2012 10

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Head and Neck – Examine closely for: -       Scalp infection (e.g. seborrheic dermatitis, tinea capitius) -       Conjunctivitis injection -       Oropharynx for pharyngitis, dental problems, HSV ginivostomatitis -       Ears for acute otitis media Abdomen – Examine closely for: -       Hepatosplenomegaly (this is actually considered part of your lymph node exam!) -       Abdominal masses (e.g. neuroblastoma) Skin – Examine closely for: -       Any rashes -       Petechiae, purpura, eccyhmoses (e.g. thrombocytopenia) 1/3/2012 11

Lymph Node Exam: : 

Lymph Node Exam: Size: Nodes are generally considered to be normal if they are up to 1 cm in diameter; however, some suggest that epitrochlear nodes larger than 0.5 cm or inguinal nodes larger than 1.5 cm should be considered . In children, lymph nodes larger than 2 cm in diameter (along with an abnormal chest radiograph and the absence of ear, nose and throat symptoms) were predictive of granulomatous diseases (i.e., tuberculosis, cat-scratch disease or sarcoidosis) or cancer (predominantly lymphomas). Pain/Tenderness: When a lymph node rapidly increases in size, its capsule stretches and causes pain. Pain is usually the result of an inflammatory process or suppuration, but pain may also result from hemorrhage into the necrotic center of a malignant node. The presence or absence of tenderness does not reliably differentiate benign from malignant nodes 1/3/2012 12

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Consistency: Stony-hard nodes are typically a sign of cancer, usually metastatic. Very firm, rubbery nodes suggest lymphoma. Softer nodes are the result of infections or inflammatory conditions. Suppurant nodes may be fluctuant. The term “shotty” refers to small nodes that feel like buckshot under the skin, as found in the cervical nodes of children with viral illnesses. Matting: A group of nodes that feels connected and seems to move as a unit is said to be “matted.” Nodes that are matted can be either benign (e.g., tuberculosis, sarcoidosis or malignant (e.g., metastatic carcinoma or lymphomas). 1/3/2012 13

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Location: The anatomic location of localized adenopathy will sometimes be helpful in narrowing the differential diagnosis. For example, cat-scratch disease typically causes cervical or axillary adenopathy, infectious mononucleosis causes cervical adenopathy. 1/3/2012 14

Less concerning findings: 

Less concerning findings Localized <1-2cm (depending on location) Cervical, inguinal, and axillary regions Erythema Tender Warm Fluctuant 1/3/2012 15

Worrisome findings which increase risk of malignancy: 

Worrisome findings which increase risk of malignancy Generalized adenopathy Occipital, auricular, supraclavicular, mediastinal, epitrochlear or posterior cervical nodes Firm Matted Nontender >2cm Systemic symptoms In patients with generalized lymphadenopathy, the physical examination should focus on searching for signs of systemic illness. The most helpful findings are rash, mucous membrane lesions, hepatomegaly, splenomegaly or arthritis. Splenomegaly and lymphadenopathy occur concurrently in many conditions, including mononucleosis-type syndromes, lymphocytic leukemia, lymphoma and sarcoidosis. 1/3/2012 16

Differential diagnosis: 

Differential diagnosis 1/3/2012 17

I: Generalized enlargement of more than 2 noncontiguous lymph node groups : 

I: Generalized enlargement of more than 2 noncontiguous lymph node groups Infectious viral (most common): URTI, measles, varicella , rubella, hepatitis, HIV, EBV, CMV, adenovirus Bacterial: syphilis, brucellosis, tuberculosis, typhoid fever, septicemia Fungal: histoplasmosis , coccidioidomycosis Protozoal : toxoplasmosis Non-infectious inflammatory diseases Rheumatologic diseases: Sarcoidosis , rheumatoid arthritis, SLE Storage diseases: Neimenn -Pick disease, Gaucher disease Serum sickness Rosai-Dorfman disease Malignant: leukemia, lymphoma, neuroblastoma Drug reaction : phenytoin , allopurinol Hyperthyroidism 1/3/2012 18

II: Localized (enlargement of a single node or multiple contiguous nodal regions) : 

II: Localized (enlargement of a single node or multiple contiguous nodal regions) A:Cervical (most common adenopathy in children, often infectious cause): Infectious: Viral upper respiratory infection, infectious mononucleosis (EBV, CMV), Group A Streptococcal pharyngitis , acute bacterial lymphadenitis ( e.g staphylococcus aureus ), Kawasaki disease (unilateral cervical lymph node > 1.5 cm), rubella, catscratch disease, toxoplasmosis, tuberculosis, atypical mycobacteria . Neoplastic : (malignant childhood tumours develop in the head and neck in ¼ of cases. neuroblastoma , leukemia, non- Hodgkins , and rhabdomyosarcoma are most common in those < 6 years old.  In older children, Hodgkin’s and non-Hodgkin’s lymphoma are more common. 1/3/2012 19

B.   Submaxillary and submental : 

B. Submaxillary and submental Oral and dental infections, acute lymphadenitis C.   Occipital Pediculosis capitis (lice), tinea capitis /local skin infection, rubella, roseola . D. Preauricular (rarely palpable in children) Local skin infection, chronic ophthalmic infection . E. Mediastinal (not directly palpable; assess indirectly via presence of supraclavicular adenopathy .  May manifest as cough, dysphagia , hemoptysis , or SVC syndrome – this is a medical emergency!) ALL, Lymphoma, sarcoidosis , cystic fibrosis, granulomatous disease (tuberculosis, histoplasmosis , coccidioidomycosis ) 1/3/2012 20

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F. Supraclavicular (associated with serious underlying disease) Lymphoma, tuberculosis, histoplasmosis , Coccidioidomycosis G. Axillary Local infection, Cat scratch disease, Brucellosis, reactions to immunizations , Non Hodgkin lymphoma, Juvenile rheumatoid arthritis H.   Abdominal (may manifest as abdominal pain, backache, urinary frequency, constipation, or intestinal obstruction due to intussuception ) Acute mesenteric adenitis, Lymphoma I.      Inguinal Local infection, Diaper dermatitis ,Syphilis 1/3/2012 21

Investigations: 

Investigations Complete blood count, peripheral blood smear. Erythrocyte sedimentation rate (non-specific). Rule out infectious causes: Monospot , CMV, EBV, & toxoplasma,TB skin test, Anti-HIV test, CRP, ESR. Hepatic and renal function + urinalysis (systemic disorders that can cause lymphadenopathy ). Lactate dehydrogenase , uric acid, calcium, phosphate, magnesium if malignancy suspected . Bone marrow, liver biopsies, CT or US guided lymph node biopsy. 1/3/2012 22

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Imaging Studies Chest X-ray.  This study will help determine the presence of mediastinal adenopathy and underlying pulmonary diseases including tuberculosis, coccidioidomycosis , lymphomas, and neuroblastoma . Ultrasound of the lymph node CT of the chest and/or abdomen. Supraclavicular adenopathy is highly associated with serious disease in the chest and abdomen. Nuclear medicine scanning is helpful in the evaluation of lymphomas. 1/3/2012 23

Management: 

Management Treatment with antibiotics. Bacterial infection results in large nodes that are warm, erythematous , and tender.  Start on antibiotics that cover the bacterial pathogens frequently implicated in lymphadenitis, including staphylococcus aureus and streptococcus pyogenes .  Reevaluate in 2-4 weeks. Biopsy if unchanged or larger. If malignancy is a strong possibility excisional biopsy should be considered immediately. If lymphadenitis is present, aspirate may be needed for culture. 1/3/2012 24

Lymph node biopsy: 

Lymph node biopsy 1/3/2012 25

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An enlarging node or nodes that remain enlarged after 2-3 weeks of antibiotics therapy. Nodes that are not enlarging, but that have not diminished in size after 5-6 weeks, or that do not return to normal size by 10-12 weeks, especially if associated with unexplained fever, weight loss, or HSM( enlarged supraclavicular or lower neck nodes should be biopsied earlier). 1/3/2012 26

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Enlarged nodes associated with any abnormal chest film finding. Ideally axillary and inguinal nodes are avoided as often demonstrate reactive hyperplasia. Preferred supraclavicular , cervical, epitrochlear , inguinal, axillary . 1/3/2012 27

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Usually the largest and firmest node. Complications include vascular and nerve injury. 1/3/2012 28

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1/3/2012 29 Home message

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Palpable lymph nodes are common in children and may be a normal finding or a sign of serious disease, because parents frequently are concerned about lymphadenopathy , the role of the primary care practitioner is to provide reassurance when appropriate and carry out a systematic evaluation when warranted. The history and physical examination frequently can elucidate the cause of the lymphadenopathy . Infectious diseases are the most common underlying cause, and antibiotics frequently are indicated if there is lymphadenitis. 1/3/2012 30

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Generalized lymphadenopathy is less common than localized lymphadenopathy and occurs in the setting of systemic disease. Worrisome features of lymphadenopathy that should lead to additional evaluation and possible biopsy include supraclavicular location; size greater than 2 cm in a cervical lymph node; a hard, firm, or matted consistency of an enlarged lymph node; lack of associated infectious symptoms; lack of improvement over a 4-week period; and accompanying constitutional symptoms. CBC, ESR, and chest radiographs are inexpensive, useful screening tests that can aid the clinician in determining whether a biopsy should be performed. 1/3/2012 31

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1/3/2012 35 QUESTIONS

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1/3/2012 36 THANK YOU Dr. Raghad Hemato -oncology unit