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

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

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

Common infectious causes:BacterialBacterial

Group A streptococcus Mycobacteria: typical and atypical Anaerobic bacteria Diphtheria Brucellosis Actinomycetes Gram –ve enterios

Common infectious causes:ViralViral

Epstein-Barr virus Herpes simplex Measles Mumps Coxsackie Adenovirus HIV Rubella

Common infectious causes:Fungal / *ParasiticFungal / *Parasitic

Aspergillosis Candida Cryptococcus Histoplasmosis Coccidioidomycosis Sporotrichosis Blastomycosis Toxoplasmosis*

Common Non Infectious Causes:MalignancyMalignancy

Hodgkin’s/Non-Hodgkin’s Lymphoma

Leukaemia Neuroblastoma Thyroid tumours Metastatic Rhabdomyosarcoma

Common Other Causes:

Kawasaki Disease Immunodeficiency diseases Autoimmune disease (SLE, Still’s

disease) Castleman disease Histiocytosis X Serum sickness Sarcoidosis

Mimicking Lymphadenopathy:

Branchial cleft cyst Cystic hygroma Thyroglossal duct cyst Epidermoid cyst Sternocleidomastoid tumor

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

This case Non tender Chronic onset No evidence of fungal disease No evidence of autoimmune disease

Possible diagnosis:Possible diagnosis: Tubercular Malignancy Sarcoidosis

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

Mediastinal Mass

Mediastinum- Region between the pleural sacs

Tumors arise from anterior, middle & posterior compartments

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

Anterior Mediastinum: Contents

Thymus Anterior mediastinal lymph nodes Internal mammary A & V Pericardial fat

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

Posterior Mediastinum: Contents

Descending thoracic aorta Esophagus Thoracic duct Azygos & hemiazygos vein Posterior group of mediastinal nodes Sympathetic trunk & intercostal

nerves

Origins of Mediastinal Mass

Developmental Neoplastic Infectious Traumatic Cardiovascular disorders

Anterior Mediastinal Masses:

Thymoma Teratoma Thyromegaly Lymphoma Lipoma, Fibroma - rare

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

Posterior Mediastinal Masses:

Neurogenic tumors Meningo-myelocele, meningocele Esophageal - tumor, cyst, diverticula Hiatus hernia Hernia of Foramen of Bochdalek Thoracic spine disease, Extramedullary hematopoiesis

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

DIAGNOSTIC APPROACH

Mediastinoscopy or anterior mediastinotomy can definitively diagnose anterior & middle mediastinal masses

Video assisted thoracoscopy plays an important role in diagnosis

TREATMENT & PROGNOSIS

Dictated by the etio-pathology of the mass

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

Histopathology of the lymph node showing caseating necrosis and Langhans’ type giant cells (arrow).

This case:

Non tender cervical lymph node Apyrexial CXR: mass in the anterior

mediastinum Lungs normal

Biopsy of cervical lymphnode suggestive of tuberculosis