Transcript Case presentation

Case presentation
Karen Estrella H.
PGY-1
5y 2m girl
CC: mass in axilla
HPI
 2 dys ago
 1st episode
 Tactile fever
 Tylenol 1.5tsp po x1
 Given 8 hrs ago
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+ insect bites
+ contact with cats
no recent travelling
No other complains
 Mass:
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Axilla
“not warm”
“small”
Painful
initially 7/10, now 4/10
 More w/ movement
 ROS: none
 PMHx:
 Born in the US, normal anthropometric
values, no neonatal complications
 No hospitalizations
 No surgeries
 NKA, NKDA
 Vaccines: UTD, PPD (-) 05/06/09
 Diet: family diet
 Primary care giver: mother
 PE:
 VS:
 T: 100 P: 110
RR:20 BP: 84/56
 WT: 15.7 kg
Ht: 107cm
 Gral: Alert, active, in NAD
 Skin: scars from mosquito bites, small papular lesion
on left palm
 HEENT: no nasal or ear discharge, mouth: no lesions,
ears: TM wnl
 Neck: no adenopathies
 Thorax: Heart: RRR no murmurs, Lungs: + clear BL
breath sounds
 Abdomen: BS+, soft, NT, ND, no masses
 Inguinal area: no adenopathies
 Extremities:
 Left axillary area:
 soft, oval mass (1.5cm-2cm), tender to palpation,
area of swelling 3cm, not erythematous, no signs
of discharge or opening
 Tolerable pain to active and passive movements
 More with aduction
 Other extremities: wnl
 Neuro: wnl
Lab
 CBC:
N: 65.9
11.4
6.8
L: 26.4
222
32.9
M: 7.1
Ë: 0.2
B: 0.4
Cx………: pending
Titers……: (IgM, IgG) Pending
1 week later
 After initial tx
 B. henselae titers: negative
 Blood cx: negative
 Mom says the mass persists with the
same characteristics
 PE: vitals: stable
 Left axillary mass: unchanged
Lymphadenopathy in
children
Lymphadenopathy
 Lymph nodes that area abnormal in size,
number or consistency.
 Types:
 Localized
 Generalized: 2 or > nodal groups are involved or
localized to a single area
 Pt age:
 (+) in 44% of healthy children under 5yo
 (+) in 64% of sick visits
 Size:
 Axillary and cervical: 1 cm
 Inguinal: 1.5cm
 Epitrochlear: 0.5cm
 Quality:
 Reactive: soft, easily compressible, mobile
 Infection: tender (lymphadenitis)
 Erythema, warmth, induration or fluctuant
 Malignancy: fixed, firm
Association
 Hx:
 Symptoms:
 Constitutional:
 Fever, night sweats, weight loss, pruritus, arthralgia, fatigue
 Local:
 Infection nearby organs
 Exposure
 Animals
 Unpasteurized milk
 Uncooked meat
 Medications:
 carbamazepine, cephalosporins, penicillins, phenytoin,
sulfonamides
 Time
Axillary lymphadenopathy
Differential diagnosis
 Cat-scratch disease
 Brucellosis
 M tuberculosis
 Atypical mycobacterias
 Reactions to immunizations
 Lymphoma
 Juvenile rheumathoid arthritis
Cat-scratch fever
 MCC of chronic lymphadenopathy in children
 Bartonella henselae (G- baccilli)
 90% have + hx for cat exposure (kittens)
 > in children < 10 yrs old
 Contact: bite, scratch or salive into open wound
 Rate of transmission from single contact: unknown
 Transmission by cat fleas: minor risk
 Incubation period: 7-12 days
Types:
UNCOMPLICATED:
 Nontender brownish-red papule in site of inoculation,
followed by regional adenopathy that develops 1 to 2
weeks later.
 Regional nodes continue to enlarge for 2 to 3 weeks,
then gradyally recover over the next 1 to 2 months.
 Nodes may be small and asymptomatic or become
massively enlarged and last several months.
 axillary (45%), cervical/submandibular (26%), and groin
(18%).
 May suppurate late in the course (30%)
 Fever 50%, unfrequent: malaise, anorexia, HA
COMPLICATED:
 Hepatitis
 Parinaud oculoglandular syndrome (POGS): 4% to 6%
 Conjunctival nodule, conjunctivitis, and ipsilateral
preauricular adenopathy.
 Encephalopathy: 0.3% to 2%
 CN, peripheral nerve dysfunction cerebellar ataxia,
seizures
 days to months after the onset of adenopathy
 recover completely, usually within 3 months.
Dx
 Serologic testing (gold standard)
 IgM > 1:16
 IgG: > 1:64
 Humoral response precedes or occurs as the same time as onset of
symptoms
 IgG levels rise during the 1st 2 months and then gradually decline.
 IFA:
 Sensitivity: 88-100%
 Specificity: 92-98%
 EIA:
 Sensitivity: 85%
 Specificity: 98-99%
 Other:
 PCR (endocarditis)
 Cx: from lymph node takes 6 wks, blood culture: not recommended for
lymphadenopathy
Treatment
 Self-limited
 Supportive care
 Antibiotics:
 Antibiotic therapy little or no improvement
 some improvement in regression of lymph node size after the
use of azythromycin vs placebo (1st mo)
 Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d
 USE IN: immunocompromised Pts
 Macrolides, rifampin,doxycycline,ciprofloxacin, or gentamicin.
 Suppurative lymph nodes: needle aspiration
 For complicated: steroids(?) can be added to antibiotics
Brucellosis (G- coccobacilli)
 Unpasteurized milk
 Sources:
 importation of disease (from infected food products or
international travel)
 cross-border spread from Mexico into neighboring
states (mostly affecting Hispanics)
Texas
 Symptoms: weakness, excessive sweating,
lethargy, anorexia, weight loss, arthralgia,
myalgia, abdominal pain, and headache.
 “undulant fever"
Mycobacterias
 Fluctuant lymph nodes develop in weeks to
months later
 Usually signs of inflamation are absent
 ATYPICAL (M. avium, M. scrofolaceum): from
contact w/ water or soil rather than p-p as in Tb
 Can form cutaneous sinus tracts, and spontaneous
rupture
 M. tuberculosis: PPD is weakly (+), CXR wnl,
and systemic s/s are absent
Lymphoma
 > over 10 yrs old
 2/3 of children with ALL and 1/3 of AML
 Increasing size, firm, not mobile, irregular
surface
 Constitutional symptoms (1/3 Hodgkin,
10% non-hodgkin)
 Lack of regression in size after 4-6 weeks
 Excisional biopsy
Juvenile Rheumatoid Arthritis
 Criteria:
 onset before age 16 years
 arthritis involving one or more joints, or:
 presence of at least two of the following findings:
 limitation in ROM
 tenderness or pain with joint movement
 increased fever
 disease persisting 6 weeks or longer
 clinical features of : polyarthritis (5 or > ), oligoarthritis(< 5),
systemic: characteristic arthritis that develops with fever
 Lymphadenopathy
Questions
 A worried mother brings her 4-year-old son to
your office because his right eye has been red
for 3 days. She assumed it was pink eye that he
contracted at child care, but she now is
concerned because he has developed swelling
in front of his right ear, and his eye has become
redder.

 They live in a wooded area
and got a new kitten 6 weeks
ago, but there is no history of
the kitten scratching the child.
Physical examination reveals a
well-appearing child who has
obvious conjunctival injection
of the right eye but no
discharge or pain. You palpate
a 2x2-cm tender, mobile
preauricular lymph node and a
2x3-cm anterior cervical lymph
node on the right. The
remainder of the physical
examination findings are
normal.
 Of the following, the MOST likely pathogen
causing this boy's symptoms is:
1.Haemophylus influenzae
2.Pasteurella multiocida
3.Staphylococcus aureus
4.Francisella tularensis
5.Bartonella henselae

5
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You are evaluating a 12yo girl who has a 1 mo Hx of daily fevers (
Tmax: 104), cervical adenopathy, severe malaise, headache and
lower back pain. No sick contacts at home. She has a 5 yo cat and
2 birds as pets. 6 mo ago she spent 2 wks at Mexico where she
learned to milk the cows, feed the pigs and ride horses. She also
sampled the local cuisine.
PE: febrile, tired-appearing. Diffuse 1x1 cm nontender cervical
adenopathy, splenomegaly and tenderness to palpation of her
lower back.
CBC: WBC: 4.9 x109/L with PMN: 31%, L: 48%, M:6%, Bans: 16%.
ESR 70
Of the following, the MOST likely Dx is?
1.
2.
3.
4.
Brucellosis
Cat-scratch disease
EBV mononucleosis
Leptospirosis
1
A 14 yo male boy is referred to the hospital for evaluation of a
swollen lymph node, which his mother says has been present and
growing for the past 6 wks. The swelling has not improved after 2
wks of antibiotics. His PE reveals normal findings, with the
exception of a 3x2 cm, hard, nonmobile lymph node in the left
supraclavicular area.
Which of the following is MOST likely to confirm a Dx in this
patient?
1.
2.
3.
4.
5.
Blood culture
CXR
Excisional biopsy of the node
FNA of the node
PPD
3