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Morning Report: Friday, January 6th

LymphadenopathyEvaluation and Management

The Lymphatic System

Open circulatory system Component of the immune system

Lymph= lymphocytes + ultrafiltrate Lymph Nodes

Body has ~600! Infectious organisms phagocytosed, processed, and presented as Ags to surrounding lymphocytes Ab production, T-cell responses, andCytokine production all occur here!

Lymphadenopathy

LN that are abnormal in size, number or consistency

DDx depends on important clinical features Age of the patient Size of the nodes Location of the nodes Quality of the nodes Localized or generalized LAD Time course and associated symptoms

Age of the Patient

Normal sizes of various LN change with age LN generally not palpable in the newborn

Consider congenital lesions Cystic hygroma Branchial cleft cyst Thyroglossal duct cyst Cervical rib

Cervical, axillary and inguinal LAD normal through early childhood (3-5 yrs)

Hodgkin lymphoma rare before 10 yo Consider STDs in adolescents

A Question… You are evaluating a 6 yo girl who was brought to the office

because of R neck swelling and redness of two days duration. She has had fever to 101F and no other recent symptoms, but her mother reports similar previous episodes several times in the past and occasional drainage from the skin in that area. Her PE reveals a 2x2cm erythematous, tender mass just anterior to the SCM muscle. The rest of the PE findings are normal. Which of the following is the most likely diagnosis?

A. Atypical mycobacterial infection B. Branchial cleft cyst C. Cystic hygroma D. Infectious mononucleosis E. Thyroglossal duct cyst

Size of the Node(s)

Rule of thumb… Cervical and axillary nodes: 1.0 cm Inguinal nodes: 1.5 cm Epitrochlear nodes: 0.5cm

Risk of underlying malignancy increases with increasing size of LN

Location of the Node(s)

Can indicate potential sources of infection

Can prompt an immediate and thorough evaluation, with malignancy high on the differential

Location of the Node(s)

Quality of the Node(s)

Soft, easily compressible, freely mobile Benign

Tender with associated erythema, warmth, induration or fluctuance

Infection Hard, firm and rubbery, fixed, matted

MALIGNANCY!!!

Localized vs. Generalized LAD

Localized More common (Cervical) Can occur from:

Infection of the node itself Infection in the node’s drainage area

Generalized Caused by systemic disease

HSM and rash common

Time Course and Associated Sx

*Biopsy indicated: No decrease in size of nodes by 4-6 wks Lack of complete normalization by 8-12wks

Associated features/ symptoms Exposures?

Animals, uncooked meats, unpasteurized milk Medications? Associated constitutional symptoms?

Fever, night sweats, weight loss, pruritis, arthralgias, fatigue

*Differential Diagnosis

Reactive Lymph Nodes

Most common cause of localized enlarged LN in children

Frequent antigenic exposure in early childhood to common childhood illness and the gradual acquisition of antibodies and immunity

Pharyngitis, OM, conjunctivitis cervical LAD

Lymphadenitis

Presentation Acute onset Inflamed, enlarged, tender lymph nodes +/- fever +/- progression to fluctuation

Most common offending agents: S. aureus Group A Streptococcus Consider anaerobic organisms in older children

Lymphadenitis

*Management Cultures of drainage or pharyngeal exudate Antibiotics Incision and drainage for abscess formation

More indolent causes… Bartonella henselae Mycobacterium tuberculosis Atypical mycobacteria

A Question… A previously healthy 12 yo girl comes to your office with the

complaint of fatigue for 2 weeks, fever and sore throat for 1 week, and decreased oral intake due to throat pain. Her PE reveals a T101F and otherwise normal VS. She is tired-appearing but nontoxic. Her throat is very erythematous, with copious yellowish tonsillar discharge and she has difficulty swallowing. Several 2x2cm, slightly tender LN are palpable posterior to the SCM muscles bilaterally, and shotty inguinal LAD is noted. Her spleen is palpable 3 cm below the costal margin. The remainder of the PE is normal. Which of the following is the most likely diagnosis?

A. Cat-scratch disease B. Hodgkin disease C. Infectious mononucleosis D. JIA E. Kawasaki disease

Infectious Mononucleosis

Presentation Fever Pharyngitis LAD (post>anterior cervical)

Fatigue, splenomegaly, malaise, hepatitis, atypical lymphocytosis

Common offending agents EBV CMV HIV

Generalized Lymphadenopathy

Medications Serum sickness

Carbemazepine, cephalosporins, PCNs, phenytoin, sulfonamides

Malignancy Leukemia Lymphoma^

Autoimmune disease SLE JIA Dermatomyositis

*Diagnostic Evaluation

History and PE Usually will reveal the cause of the LAD

Useful laboratory tests CBC ESR/CRP LDH PPD Specific serologic testing for infectious agents CXR*

A Question… A 14 yo boy is referred to the hospital for evaluation of a

swollen LN, which his mother says has been growing for the past 6 weeks. The swelling has not improved after 2 weeks of amoxicillin. He has had intermittent low-grade fevers over the last 6 weeks. His PE reveals normal findings, with the exception of a 3x2cm hard, nonmobile LN in the left supraclavicular area. Which of the following tests is most likely to confirm a diagnosis in this patient?

A. Blood culture B. CXR C. Excisional biopsy of the node D. FNA of the node E. PPD

Lymphoma

Quick Introduction

Third most common childhood malignancy 12% of the newly diagnosed cancers seen in

children <15 yo 60% of pediatric lymphomas are non-

Hodgkin lymphoma Hodgkin disease accounts for a greater

proportion of the lymphomas seen in adolescents

Clinical Presentation

Classification of Lymphoma

Hodgkin disease Nodular sclerosing Mixed cellularity Lymphocyte predominance Lymphocyte-depleted

Non-Hodgkin lymphoma Small, noncleaved cell

Burkitt, non-Burkitt subtypes Lymphoblastic Large cell