Approach to a child with cervical lyymphadenopathy
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Transcript of Approach to a child with cervical lyymphadenopathy
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Approach to A child with cervical lymphadenopathy
Professor Pushpa Raj Professor Pushpa Raj SharmaSharma
Department of Child HealthDepartment of Child Health
Institute of MedicineInstitute of Medicine
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Location of enlarged nodes
The horizontal nodes are positioned at the junction of the head with the neck
The vertical nodes drain the deep structures of the head and neck
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Approach to a child with lymphadenopathy
Infective Tender (not in
tuberculosis) Acute onset Evidence of
infection in drainage area
Soft/fluctuant Local
Non-infective Non tender Chronic onset Evidence of
systemic manifestation
Firm/hard Generalized
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Common infectious causes:BacterialBacterial
Group A streptococcus Mycobacteria: typical and atypical Anaerobic bacteria Diphtheria Brucellosis Actinomycetes Gram –ve enterios
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Common infectious causes:ViralViral
Epstein-Barr virus Herpes simplex Measles Mumps Coxsackie Adenovirus HIV Rubella
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Common infectious causes:Fungal / *ParasiticFungal / *Parasitic
Aspergillosis Candida Cryptococcus Histoplasmosis Coccidioidomycosis Sporotrichosis Blastomycosis Toxoplasmosis*
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Common Non Infectious Causes:MalignancyMalignancy
Hodgkin’s/Non-Hodgkin’s Lymphoma
Leukaemia Neuroblastoma Thyroid tumours Metastatic Rhabdomyosarcoma
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Common Other Causes:
Kawasaki Disease Immunodeficiency diseases Autoimmune disease (SLE, Still’s
disease) Castleman disease Histiocytosis X Serum sickness Sarcoidosis
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Mimicking Lymphadenopathy:
Branchial cleft cyst Cystic hygroma Thyroglossal duct cyst Epidermoid cyst Sternocleidomastoid tumor
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CASE PRESENTATION
10 year old; Male from Ramechap
Swelling in the neck 5 months
Fever for one month Weight: 15 Kg; Height:
113 cms Physical Exam – Multiple
lymph nodes in the neck; vertical and horizontal; non tender; mobile;
other: unremarkable
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This case Non tender Chronic onset No evidence of fungal disease No evidence of autoimmune disease
Possible diagnosis:Possible diagnosis: Tubercular Malignancy Sarcoidosis
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Investigations Had a routine CXR Blood: WBC:
7,000/cmm; N: 72%; L: 28%; Hb: 8.4gm%.
Mediastinal Mediastinal mass: mass: a. a. MalignancyMalignancy
b. Tubercularb. Tubercularc. Sarcoidosisc. Sarcoidosis
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Mediastinal Mass
Mediastinum- Region between the pleural sacs
Tumors arise from anterior, middle & posterior compartments
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Extent of Mediastinum
Anterior - sternum anteriorly to pericardium & brachiocephalic vessels posteriorly
Middle - between the anterior & posterior compartments
Posterior - pericardium & trachea anteriorly to vertebral column posteriorly
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Anterior Mediastinum: Contents
Thymus Anterior mediastinal lymph nodes Internal mammary A & V Pericardial fat
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Middle Mediastinum: Contents
Heart & Pericardium, ascending aorta & arch of aorta, vena cavae, brachiocephalic A &V ,
phrenic nerve trachea, main stem bronchi &
contiguous lymph nodes Pulmonary A & V
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Posterior Mediastinum: Contents
Descending thoracic aorta Esophagus Thoracic duct Azygos & hemiazygos vein Posterior group of mediastinal nodes Sympathetic trunk & intercostal
nerves
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Origins of Mediastinal Mass
Developmental Neoplastic Infectious Traumatic Cardiovascular disorders
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Anterior Mediastinal Masses:
Thymoma Teratoma Thyromegaly Lymphoma Lipoma, Fibroma - rare
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Middle Mediastinal Masses:
Aneurysms - aorta, innominate artery, enlarged pulmonary artery
Lymphadenopathy secondary to carcinoma / metastasis / granulomatosis
Cysts - enteric, bronchogenic, pleuropericardial
Dilated azygos, hemiazygos veins Hernia of Foramen of Morgagni
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Posterior Mediastinal Masses:
Neurogenic tumors Meningo-myelocele, meningocele Esophageal - tumor, cyst, diverticula Hiatus hernia Hernia of Foramen of Bochdalek Thoracic spine disease, Extramedullary hematopoiesis
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DIAGNOSTIC APPROACH
Imaging - CT, MRI, Radionuclide study,
Tissue sampling - Mediastinoscopy, Thoracoscopy, Needle aspiration, Open Biopsy
Barium study for hernia, achalasia, diverticula
I-131 for intrathoracic goiter
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DIAGNOSTIC APPROACH
Mediastinoscopy or anterior mediastinotomy can definitively diagnose anterior & middle mediastinal masses
Video assisted thoracoscopy plays an important role in diagnosis
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TREATMENT & PROGNOSIS
Dictated by the etio-pathology of the mass
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This case Nospecific- no pressure effect of
mass sorrounding structures Chronic onset with fever and loss
of weight mass detected on CXR Physical findings : cervical
lymphadenopathy; fever; loss of weight. 50% mediastinal masses are
malignant in children
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Histopathology of the lymph node showing caseating necrosis and Langhans’ type giant cells (arrow).
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This case:
Non tender cervical lymph node Apyrexial CXR: mass in the anterior
mediastinum Lungs normal
Biopsy of cervical lymphnode suggestive of tuberculosis