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Approach to A child with cervical lymphadenopathy Professor Pushpa Raj Sharma Department of Child Health Institute of Medicine.

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Presentation on theme: "Approach to A child with cervical lymphadenopathy Professor Pushpa Raj Sharma Department of Child Health Institute of Medicine."— Presentation transcript:

1 Approach to A child with cervical lymphadenopathy Professor Pushpa Raj Sharma Department of Child Health Institute of Medicine

2 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

3 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

4 Bacterial Common infectious causes: Bacterial Group A streptococcus Mycobacteria: typical and atypical Anaerobic bacteria Diphtheria Brucellosis Actinomycetes Gram –ve enterios

5 Viral Common infectious causes: Viral Epstein-Barr virus Herpes simplex Measles Mumps Coxsackie Adenovirus HIV Rubella

6 Fungal / *Parasitic Common infectious causes: Fungal / *Parasitic Aspergillosis Candida Cryptococcus Histoplasmosis Coccidioidomycosis Sporotrichosis Blastomycosis Toxoplasmosis*

7 Malignancy Common Non Infectious Causes: Malignancy Hodgkin’s/Non-Hodgkin’s Lymphoma Leukaemia Neuroblastoma Thyroid tumours Metastatic Rhabdomyosarcoma

8 Common Other Causes: Kawasaki Disease Immunodeficiency diseases Autoimmune disease (SLE, Still’s disease) Castleman disease Histiocytosis X Serum sickness Sarcoidosis

9 Mimicking Lymphadenopathy: Branchial cleft cyst Cystic hygroma Thyroglossal duct cyst Epidermoid cyst Sternocleidomastoid tumor

10 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

11 This case Non tender Chronic onset No evidence of fungal disease No evidence of autoimmune disease Possible diagnosis: Tubercular Malignancy Sarcoidosis

12 Investigations Had a routine CXR Blood: WBC: 7,000/cmm; N: 72%; L: 28%; Hb: 8.4gm%. Mediastinal mass: a. Malignancy Mediastinal mass: a. Malignancy b. Tubercular c. Sarcoidosis

13 Mediastinal Mass Mediastinum- Region between the pleural sacs Tumors arise from anterior, middle & posterior compartments

14 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

15 Anterior Mediastinum: Contents Thymus Anterior mediastinal lymph nodes Internal mammary A & V Pericardial fat

16 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

17 Posterior Mediastinum: Contents Descending thoracic aorta Esophagus Thoracic duct Azygos & hemiazygos vein Posterior group of mediastinal nodes Sympathetic trunk & intercostal nerves

18 Origins of Mediastinal Mass Developmental Neoplastic Infectious Traumatic Cardiovascular disorders

19 Anterior Mediastinal Masses: Thymoma Teratoma Thyromegaly Lymphoma Lipoma, Fibroma - rare

20 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

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

22 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

23 DIAGNOSTIC APPROACH Mediastinoscopy or anterior mediastinotomy can definitively diagnose anterior & middle mediastinal masses Video assisted thoracoscopy plays an important role in diagnosis

24 TREATMENT & PROGNOSIS Dictated by the etio-pathology of the mass

25 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

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

27 This case: Non tender cervical lymph node Apyrexial CXR: mass in the anterior mediastinum Lungs normal Biopsy of cervical lymphnode suggestive of tuberculosis

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