Lymphadenopathy
Lymphadenopathy: Excerpt from In A Page: Pediatric Signs and Symptoms
Lymphadenopathy, both localized and systemic, is an extremely common presenting symptom encountered by practicing pediatricians. To be considered enlarged, nodes must be at least 1 cm in cervical and axillary regions and
1.5 cm in the inguinal region. Most children have shotty adenopathy, usually due to uncomplicated infections that are transient and self-limited. Stepwise management (obtain clues from history, physical examination, and less invasive testing) will aid in selecting appropriate patients for further workup.
Differential Diagnosis
- Infectious
–Viral (URI, varicella, EBV, CMV, HIV, rubella, mumps, measles)
–Bacterial (strep, staph, mycobacterium, atypical mycobacterium, brucellosis, tularemia, syphilis, chlamydia)
–Fungal (histoplasmosis, coccidioidomycosis)
–Protozoal (toxoplasmosis, malaria)
–Scalp infection
-
Allergy
–Seasonal or individual
-
Inflammatory
–Kawasaki disease
–Sarcoidosis
–Cat-scratch disease (Bartonella henselae)
–Drug-induced (phenytoin, isoniazid,
hydralazine, dapsone, procainamide, allopurinol)
-
Malignancy
–Leukemia
–Hodgkin disease
–Non-Hodgkin lymphoma
–Neuroblastoma
–Rhabdomyosarcoma
–Histiocytic disorder
-
Collagen vascular disease or systemic illness
–Rheumatoid arthritis
–Systemic lupus erythematosus
–Serum sickness
–Autoimmune hemolytic anemia
–Cystic fibrosis
-
Immunodeficiency
-
Storage diseases
–Gaucher disease
–Niemann-Pick disease
-
Non-lymph node masses simulating
lympadenopathy
–Thyroglossal duct cysts
–Branchial cleft cysts
–Cystic hygroma
–Hemangioma
–Teratoma
–Thymoma
–Inguinal hernia
Workup and Diagnosis
-
History
–Duration, fever, weight loss, night sweats
–Sore throat, rash, limp, joint swelling/pain, bone pain
–Sexual history and HIV risk factors
–Exposures: Food contamination, pets (e.g., kittens)
–Immunizations, recurrent infections, meds, allergies
–Long-standing or unexplained skin rash, transfusions
–Family history of autoimmune/inflammatory diseases
-
Physical exam
–All lymph node chains: Size, tenderness, fluctuance,
consistency, warmth, surrounding erythema
–Splenomegaly, hepatomegaly
–Trauma or animal/insect bites along lymph drainage
–Rash, including “eczema,” lesions, petechiae, purpura
–Signs of respiratory compromise
–Scalp for signs of infection
–Genitalia for signs of sexually transmitted disease
- Labs
–Common: CBC/peripheral smear, ESR, LDH, electrolytes, BUN, Cr, LFT, uric acid, EBV, CMV, B. henselae titers, PPD, throat culture
–Less common: ANA, ACE level, anti-dsDNA, specific infection titers, immunodeficiency workup - Studies
–Chest X-ray; bone marrow exam; biopsy or I&D of node, echo/ECG, biopsy of rash
Treatment
-
Mild adenopathy with associated viral/URI symptoms
–Observation and recheck in 1–2 weeks
–Malignancy-associated adenopathy can sometimes wax
and wane (especially Hodgkin disease) and appear to improve with antibiotics
–TB nodes may be firm, matted, fixed, and nontender
-
Erythematous, warm, tender nodes
–Trial of oral antibiotics for staph/strep
-
Inflamed/fluctuant lesions: Referral for I&D
-
Refer to pediatric hematologist/oncologist
–Nodes that fail to resolve over 6 weeks
–Nodes that increase in size over 2 weeks
–Firm, matted nodes
–Supraclavicular nodes
–Nodes that generalize to two or more noncontiguous
groups or more than two contiguous groups
-
CBC with differential, CXR before biopsy
Book Source Details
- Book Title: In A Page: Pediatric Signs and Symptoms
- Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
- Year of Publication: 2007
- Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: In A Page: Pediatric Signs and Symptoms
Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 1-4051-0427-9
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LYMPHADENOPATHY, GENERALIZED (Differential Diagnosis in Primary Care)
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