5 Epidemiology Rece is not a major criteria. Sex: M/F=1 Age: most frequent in younger children, less frequent in newborn.
6 PathophsiologyIncrease in the number of benign lymphocytes and macrophages in the process of response to antigensInfiltration of the lymph nodes with the inflammatory cells during infectionInfiltration of the lymph nodes with metastatic malignant cellsIn situ proliferation of lymphocytes and macrophagesInfiltration of the lymph nodes with metabolite-laden macrophages during storage diseases
7 I. Generalized Lenfadenopahy A- InfectionB- Neoplastic ve proliferative disordersC- Storage diseasesD- Autoimmune disorders and hypersensitivity reactions
26 criteria for LAP differs in pediatric age group. small, hard, a few mm in diameterbilateral ant. cervicalAxillaryInguinalOccipitalNormal< 2 cm.< 1 cm.< 1.5 cm.
27 LAP in newborn is always abnormal Lymph nodes >10 mm are considered enlargedEpitrochlearInguinalPosterior auricular, epitrochlear and supraclavicularAbnormaleven 5 mm.> 15 mm.
28 History and PE History: Duration Accompanying condition: eg: contact with cats,rodent bite, tick bite, tonsillitis, skin lesions etc…Symptoms (fever, weight loss, night sweats)Medications: fenitoin, cephalosporins,sulphonamids…Travel history
29 Physical examination: Localization:tonsillar and inguinal lymph nodes: secondary to localized infectionsSupraclavicular (SC) and axillary lymph nodes (even if<0.5 cm. ) warrant further investigationleft SC: intraabdominal malignancyright SC: thoracic malignancy
30 size: character: Symptoms: hard,rubbery ones without tenderness and redness suggest malignancy. Occasionally rapid growing malignant lymph node may be tenderWarm, tender and fluctuant lymph nodes suggest infection or inflammation (lymphadenitis)Symptoms:Localized paintendernessredness
31 Dysphagia and respiratory difficulty occur as a result of abscess formation of the retropharyngeal nodes.cyanosis, dyspnea, stridor, cough, fascial edema suggest mediastinal LAPAbdominal pain suggests mesenteric and retroperitoneal LAP
32 Work-up for localized or generalized LAP Thorough history of infection, contact with rodents or cats and systemic complaintsPhysical examination for evidence of hematologic disease, such as hepatosplenomegaly and petechiae)Blood count and, ESRSkin tests (Tb, Cat scratch disease, fungal infections)Cultures (from the regional lesions throat etc.Serologic tests (Toxoplazmozis, CMV,EBV,HIV..etc)
33 Chest radiograph and CT scan (if necessary); abdominal sonogram and CT, if indicated Ultrasonography is useful in an acute setting in assessing whether a swelling is nodal in origin, an infected cyst or other soft tissue mass. It may detect an abscess requiring drainageLymph node aspiration and culture; helpful in isolating the causative organism and deciding on an appropriate antibiotic when infection is the cause of the lymphadenopathyFine needle aspiration; may yield a definite or preliminary cytologic diagnosis andoccasionally obviate the need for lymph node biopsy; it provides limited material in the event flow cytometry is required and negative results cannot rule out a malignancy because the sample may be inadequateBone marrow examination if leukemia or lymphoma is suspectedLymph node biopsy
35 Indications for lymph node biopsy Lymph node biopsy is indicated if:• Initial physical examination and history suggest malignancy• Lymph node size is greater than 2.5 cm in absence of signs of infection• Lymph node persists or enlarges• Appropriate antibiotics fail to shrink node within 2 weeks• Supraclavicular adenopathy.
36 Following precautions should be observed during Bx Upper cervical and inguinal areas should be avoided; lower cervical and axillary nodes are more likely to give reliable informationThe largest node should be biopsied, not the most accessible one. The oncologist should select the node to be biopsied in consultation with the surgeonThe node should be removed intact with the capsule, not piecemealThe lymph node should be immediately submitted to the pathologist fresh or in sufficient tissue culture medium.The node must not be left in strong lightit should not be wrapped in dry gauze.Fresh and frozen samples should be set aside for additional studies
37 What to do with the biopsy 1-culture: bacterial,viral,fungal and gram staining2-viral studies3-histologic examination4-light and electron microscopy5-immunohystochemical staning: in order to differenciate the tumor type6-flow cytometry: to decide upon the type of leukemia or lymphoma7-genetic investigations