Transcript BUHMC - www.prsharma.com.np

Approach to A child with
cervical lymphadenopathy
Professor Pushpa Raj Sharma
Department of Child Health
Institute 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
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Infective
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Tender (not in
tuberculosis)
Acute onset
Evidence of
infection in
drainage area
Soft/fluctuant
Local
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Non-infective
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Non tender
Chronic onset
Evidence of
systemic
manifestation
Firm/hard
Generalized
Common infectious causes:
Bacterial
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Group A streptococcus
Mycobacteria: typical and atypical
Anaerobic bacteria
Diphtheria
Brucellosis
Actinomycetes
Gram –ve enterios
Common infectious causes:
Viral
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Epstein-Barr virus
Herpes simplex
Measles
Mumps
Coxsackie
Adenovirus
HIV
Rubella
Common infectious causes:
Fungal / *Parasitic
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Aspergillosis
Candida
Cryptococcus
Histoplasmosis
Coccidioidomycosis
Sporotrichosis
Blastomycosis
Toxoplasmosis*
Common Non Infectious Causes:
Malignancy
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Hodgkin’s/Non-Hodgkin’s Lymphoma
Leukaemia
Neuroblastoma
Thyroid tumours
Metastatic
Rhabdomyosarcoma
Common Other Causes:
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Kawasaki Disease
Immunodeficiency diseases
Autoimmune disease (SLE, Still’s disease)
Castleman disease
Histiocytosis X
Serum sickness
Sarcoidosis
Mimicking Lymphadenopathy:
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Branchial cleft cyst
Cystic hygroma
Thyroglossal duct cyst
Epidermoid cyst
Sternocleidomastoid tumor
CASE PRESENTATION
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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
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Non tender
Chronic onset
No evidence of fungal disease
No evidence of autoimmune disease
Possible diagnosis:
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Tubercular
Malignancy
Sarcoidosis
Investigations
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Had a routine CXR
Blood: WBC:
7,000/cmm; N: 72%;
L: 28%; Hb: 8.4gm%.
Mediastinal mass:
a. Malignancy
b. Tubercular
c. Sarcoidosis
Mediastinal Mass
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Mediastinum- Region between the
pleural sacs
Tumors arise from anterior, middle &
posterior compartments
Extent of Mediastinum
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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
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Thymus
Anterior mediastinal lymph nodes
Internal mammary A & V
Pericardial fat
Middle Mediastinum: Contents
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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
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Descending thoracic aorta
Esophagus
Thoracic duct
Azygos & hemiazygos vein
Posterior group of mediastinal nodes
Sympathetic trunk & intercostal nerves
Origins of Mediastinal Mass
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Developmental
Neoplastic
Infectious
Traumatic
Cardiovascular disorders
Anterior Mediastinal Masses:
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Thymoma
Teratoma
Thyromegaly
Lymphoma
Lipoma, Fibroma - rare
Middle Mediastinal Masses:
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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:
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Neurogenic tumors
Meningo-myelocele, meningocele
Esophageal - tumor, cyst, diverticula
Hiatus hernia
Hernia of Foramen of Bochdalek
Thoracic spine disease,
Extramedullary hematopoiesis
DIAGNOSTIC APPROACH
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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
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Mediastinoscopy or
anterior mediastinotomy can definitively
diagnose anterior & middle mediastinal
masses
Video assisted thoracoscopy plays an
important role in diagnosis
TREATMENT & PROGNOSIS
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Dictated by the etio-pathology of the
mass
This case
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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.
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50% mediastinal masses are
malignant in children
Histopathology of the lymph node
showing caseating necrosis and Langhans’
type giant cells (arrow).
This case:
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Non tender cervical lymph node
Apyrexial
CXR: mass in the anterior mediastinum
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Lungs normal
Biopsy of cervical lymphnode
suggestive of tuberculosis