Y H T A P O N E LYMPHAD The McMaster at night Pediatric Curriculum Sahai, S. “Lymphadenopathy”. Pediatrics in Review 34 (5). 2013. Objectives •  Define lymphadenopathy •  Consider various investigations in the work-up for lymphadenopathy •  Know the differential diagnosis for localized and generalized lymphadenopathy •  Recognize “red flags” associated with noninfectious causes of lymphadenopathy Background •  Lymphadenopathy – An abnormality in size and consistency of lymph nodes •  Lymphadenitis – Lymphadenopathy that occurs from infectious and other inflammatory processes •  Generalized Lymphadenopathy – Involves 2 or more noncontiguous regions •  Lymph node enlargement is a common finding on physical exam in children •  Infections are the most common cause of lymph node enlargement • Primary Lymphoid Organs: (Sites for generation of B and T lymphocytes) - Bone marrow - Thymus • Secondary Lymphoid Organs: - Lymph nodes - Spleen - Mucosa-Associated Lymphoid Tissue (MALT) • Tonsils • Appendix • Solitary lymphoid nodules • Peyer patches of the ileum Test Your Knowledge •  Which of the following lymph nodes is considered enlarged in a child? A.  B.  C.  D.  Axillary lymph node 1cm Cervical lymph node 1.5cm Inguinal lymph node 1.5cm Epitrochlear lymph node 0.5cm The Answer The normal size for lymph nodes in children is as follows: - Axillary region – Up to 1cm - Cervical region – Up to 1cm - Inguinal region – Up to 1.5cm B - Epitrochlear region – Up to 0.5cm The Case •  A 4 year old girl presents to the ER with a 1 week history of fever and progressive neck swelling on the right •  The area of swelling is tender to palpation, slightly erythematous, mobile, ~3cm in diameter •  She is previously well History What would you ask? History •  Preceding symptoms (ie URTI, sore throat, etc) •  Localizing signs or symptoms (ie stomatitis may be associated with mandibular nodes) •  Duration: Days or weeks •  Constitutional or Associated Symptoms: Fever, Weight loss, Night sweats, Fatigue, etc •  Exposures: Cat exposure, Uncooked meat (toxoplasmosis), Tick bite (lyme disease) •  Medications: ie Phenytoin, Isoniazid •  Travel history •  Sick contacts Physical Exam What would you look for? Physical Exam •  Vitals (HR, RR, Temp), Weight, Pallor •  •  •  •  •  H&N – Ears, Throat (tonsils), Discharge from Eyes/Nose Resp – ?Equal A/E, Cough, Wheeze, SOB when lying flat Abdo – HSM, Masses MSK – Swelling, Erythema, Pain Skin – Rashes, Bite marks, Scratches •  Lymph Nodes – Head & Neck, Supraclavicular, Deltopectoral, Axillary, Epitrochlear, Inguinal, Popliteal (see graph in next slides) •  Location, Size, Number, Fluctuance, Tenderness, Mobility Lymph Nodes of the Head and Neck and Their Drainage Areas blood disorders Lymph Node Regions in the Body and the Areas They Drain Examination o and Lymphatic The size of the enla aids in determining ther evaluation. Lym than 2 cm are mor a more serious dise number of lymph no sistency, ﬂuctuance, bility, and presen should be noted. characterized by sw nodes in conjunctio changes in the fo and edema, and ten areas of potential largement should b presence of liver an ment should be eva It is important drainage area in c lymphadenopathy. neck, and orophar tion may reveal a pr Figure 2. Lymph node regions in the body. Reproduced with permission from: McClain, KL, Fletcher fection. The presen RH. Causes of Peripheral Lymphadenopathy in Children. In: UpToDate, Basow DS (Ed), UpToDate, petechiae may help Waltham, MA 2013. Copyright 2013. UpToDate Inc. For more information, visit www.uptodate.com. nosis. Conjunctival exudates may be present in patients with clues in cases of chronic lymphadenopathy. Poor weight Exudative conjunctivitis is present in infe gain may be present when the lymphadenopathy is Workup What would you order? Workup •  Bloodwork •  CBC+diff, CRP, Blood culture •  Specific serology – EBV, HIV, CMV, Parvovirus, Bartonella, etc •  LDH, Uric Acid, Liver Enzymes (if worried about malignancy/infiltrative process) •  Ultrasound •  Assess for abscess and size of nodes •  Chest and/or Neck X-Ray (consider) •  Assess for mediastinal widening, Hilar lymph node enlargement, Calcifications (TB) •  Fine Needle Aspiration (consider) •  Excisional Biopsy (consider) When to Consider Possible Lymph Node Biopsy • Size • >2cm • Increasing over 2 weeks OR no decrease in size of node after 4 weeks • Location • Supraclavicular lymph node • Consistency • Hard, Matted, Rubbery • Associated Features • Fever, Weight loss, HSM, CXR suggestive of lymphoma Differential Diagnosis: Localized Lymphadenopathy Table 3. Sites of Local Lymphadenopathy and Associated Diseases Cervical Oropharyngeal infection (viral, group A streptococcal, staphylococcal) Scalp infection Mycobacterial lymphadenitis (tuberculosis and nontuberculous mycobacteria) Viral infection (EBV, CMV, HHV-6) Cat scratch disease Toxoplasmosis Kawasaki disease Thyroid disease Kikuchi disease Sinus histiocytosis Autoimmune lymphoproliferative disease Anterior auricular Conjunctivitis Other eye infection Oculoglandular tularemia Cat scratch disease Facial cellulitis Otitis media Viral infection (especially rubella, parvovirus) Cat scratch disease Toxoplasmosis Kawasaki disease Thyroid disease Kikuchi disease Sinus histiocytosis Autoimmune lymphoproliferative disease Anterior auricular Conjunctivitis Other eye infection Oculoglandular tularemia Cat scratch disease Facial cellulitis Otitis media Viral infection (especially rubella, parvovirus) Supraclavicular Malignancy or infection in the mediastinum (right) Metastatic malignancy from the abdomen (left) Lymphoma Tuberculosis Epitrochlear Hand infection, arm infection* Cat scratch disease Lymphoma[†] Sarcoid Syphilis Inguinal Otitis media Viral infection (especially rubella, parvovirus) Supraclavicular Malignancy or infection in the mediastinum (right) Metastatic malignancy from the abdomen (left) Lymphoma Tuberculosis Epitrochlear Hand infection, arm infection* Cat scratch disease Lymphoma[†] Sarcoid Syphilis Inguinal Urinary tract infection Venereal disease (especially syphilis or lymphogranuloma venereum) Other perineal infections Lower extremity suppurative infection Plague Hilar (not palpable, found on chest radiograph or CT) Tuberculosis[†] Histoplasmosis[†] Blastomycosis[†] Coccidioidomycosis[†] Leukemia/lymphoma[†] Hodgkin disease[†] [†] Blastomycosis Syphilis [†] Coccidioidomycosis Inguinal Leukemia/lymphoma[†] Urinary tract infection Hodgkin disease[†] Venereal disease (especially syphilis or lymphogranuloma venereum) Metastatic malignancy* Other perineal infections Lower extremity suppurative infection Sarcoidosis[†] Plague Castleman disease Hilar (not palpable, found on chest radiograph or CT) Axillary Tuberculosis[†] Cat scratch disease [†] Histoplasmosis Arm or chest wall infection [†] Blastomycosis Malignancy of chest wall [†] Coccidioidomycosis Leukemia/lymphoma Leukemia/lymphoma[†] Brucellosis Hodgkin disease[†] Abdominal Metastatic malignancy* Malignancies Sarcoidosis[†] Mesenteric adenitis (measles, tuberculosis, Yersinia, group A Streptococcus) Castleman disease Axillary This table was published in Practical strategies in pediatric diagnosis and therapy, 2nd ed, by Kliegman RM, Greenbaum LA, Cat scratch disease CMV¼cytomegalovirus; CT¼computed tomography; EBV¼Epstein-Barr virus; HHV-6¼human herpesvirus 6. Arm or chest wall infection *Unilateral. †Bilateral. Malignancy of chest wall Leukemia/lymphoma P Brucellosis Abdominal Malignancies Mesenteric adenitis (measles, tuberculosis, Yersinia, group A Streptococcus) Lymphadenitis-Causing Bacteria Atypical mycobacteri lymphadenitis. In the Uni States, 70% to 95% of mycobacte Bacteria Clinical features lymphadenitis is due to atypical m ACUTE cobacteria. Nontuberculous aty Streptococcus pyogenes Associate tonsillopharyngitis cal mycobacteria are acquired fro Group B Streptococcus Infants, unilateral facial or submandibular swelling environmental source; they exist May have associated dental and Anaerobic such as Bacteroides species, saprophytes in water and soil. Su gingival disease Peptococcus species, Propionibacterium mandibular lymphadenopathy is acnes, and Fusobacterium nucleatum most common presentation. F Francisella tularensis percent of patients who have non Pasteurella multocida May occur after animal bites or scratch berculous lymphadenitis develop Yersinia pestis Flea bites on head and neck in abscess. Sinus tract formation m western United States occur in 10% of these patients. Id Haemophilus influenzae type B tiﬁcation of the bacteria along w Rare gram-negative bacilli, pneumococcus, a drug susceptibility proﬁle is help Group C streptococci, Yersinia enterocolitica, Staphylococcus in management. Atypical mycobac epidermidis, alpha hemolytic ria respond poorly to antibiotics a streptococci these infections require surgical ex SUBACUTE sion. If surgery cannot be perform Rapid onset nodal enlargement, Atypical mycobacterium species such as a 3- to 6-month course of antibio overlying skin becomes avium-intracellulare (common), erythematous, thin and scrofulaceum, kansasii (common), is recommended. Clarithromycin parchment like fortuitum, haemophilum erythromycin combined with rifabu Mycobacterium tuberculosis High risk groups like immigrant or ethambutol may be effective. populations, travel or residence in Tuberculous lymphadenitis. T endemic areas presence of 2 of the following 3 c Bartonella henselae History of contact with kittens, large single lymph node enlargement, teria has 92% sensitivity in identify systemic involvement tuberculous lymphadenitis. The c teria are (1) a positive PPD skin t result, (2) an abnormal chest radiograph, and (3) cont Up to 80% of acute unilateral cervical lymphadenitis in with a person who has infectious TB. The PPD may be p children younger than age 5 years are due to infections with Staphylococcus aureus and Streptococcus pyogenes. Anitive in atypical mycobacterial infection. Tuberculo tibiotic therapy is directed at antibiotics that will cover lymphadenitis requires treatment with multiple antitub culous antibiotics for 18 months. Surgical treatment is S pyogenes and methicillin-resistant S aureus. Children quired rarely. older than age 5 years who have dental or periodontal disTable 6. Differential Diagnosis: Generalized Lymphadenopathy Table 2. Differential Diagnosis of Systemic Generalized Lymphadenopathy Infant COMMON CAUSES Syphilis Toxoplasmosis CMV HIV RARE CAUSES Chagas disease (congenital) Congenital leukemia Congenital tuberculosis Reticuloendotheliosis Lymphoproliferative disease Metabolic storage disease Histiocytic disorders Child Adolescent Viral infection EBV CMV HIV Toxoplasmosis Viral infection EBV CMV HIV Toxoplasmosis Syphilis Serum sickness SLE, JRA Leukemia/lymphoma Tuberculosis Measles Sarcoidosis Fungal infection Plague Langerhans cell histiocytosis Chronic granulomatous disease Sinus histiocytosis Drug reaction Serum sickness SLE, JRA Leukemia/lymphoma/Hodgkin disease Lymphoproliferative disease Tuberculosis Histoplasmosis Sarcoidosis Fungal infection Plague Drug reaction Castleman disease This table was published in Practical Strategies in Pediatric Diagnosis and Therapy. 2nd edition, by Kliegman RM, Greenbaum LA, Lye PS, p 863. Copyright Elsevier, 2004. Author’s note: Hemophagocytic lymphohistiocytosis may also be a cause of generalized lymphadenopathy. CMV¼cytomegalovirus; EBV¼Epstein-Barr virus; HIV¼human immunodeﬁciency virus; JRA¼juvenile rheumatoid arthritis (Still disease); SLE¼systemic lupus erythematosus. Investigations also may be indicative of bone marrow involvement with Red Flags for Malignancy •  •  •  •  •  •  •  •  •  •  Supraclavicular lymph nodes Hard consistency Rubbery consistency Absence of head and neck infection Unexplained fevers > 1 week Night sweats Weight loss Mediastinal widening on CXR Hepatosplenomegaly Abnormal labs (consistent with leukemia/ lymphoma) Test Your Knowledge •  A 2 year old child presents with a 7 day history of high grade fever, irritability, right-sided cervical lymphadenopathy measuring 2cm, non-exudative conjunctivitis, a rash, swelling of hands and feet. A.  B.  C.  D.  Streptococcal infection Adenovirus Kawasaki Disease Mononucleosis The Answer •  Kawasaki Disease is defined as fever > 5 days plus at least four of the following: 1.  Bilateral non-purulent conjunctivitis 2.  Mucosal changes (red fissured lips, strawberry tongue, pharyngeal erythema) 3.  Red edematous hands and feet with C eventual desquamation 4.  Polymorphic non-vesicular rash 5.  Cervical lymphadenopathy >1.5cm (usually unilateral) Summary •  Lymphadenopathy is common in children and is often benign •  Infection is the most common cause of lymphadenopathy in children •  A good history and physical exam will help to narrow the differential diagnosis •  It is important to recognize the signs of a malignant process in order to initiate an early evaluation Fin