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
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
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