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Welcome Applicants!! 

Welcome Applicants!! . Morning Report: Friday, January 6 th. Lymphadenopathy. Evaluation and Management. The Lymphatic System. Open circulatory system Component of the immune system Lymph= lymphocytes + ultrafiltrate Lymph Nodes Body has ~600! Infectious organisms phagocytosed ,

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Welcome Applicants!! 

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  1. Welcome Applicants!! Morning Report: Friday, January 6th

  2. Lymphadenopathy Evaluation and Management

  3. The Lymphatic System • Open circulatory system • Component of the immune system • Lymph= lymphocytes + ultrafiltrate • Lymph Nodes • Body has ~600! • Infectious organisms phagocytosed, processed, and presented as Ags to surrounding lymphocytes • Ab production, T-cell responses, and Cytokine production all occur here!

  4. Lymphadenopathy • LN that are abnormal in size, number or consistency • DDx depends on important clinical features • Age of the patient • Size of the nodes • Location of the nodes • Quality of the nodes • Localized or generalized LAD • Time course and associated symptoms

  5. Age of the Patient • Normal sizes of various LN change with age • LN generally not palpable in the newborn • Consider congenital lesions • Cystic hygroma • Branchial cleft cyst • Thyroglossal duct cyst • Cervical rib • Cervical, axillary and inguinal LAD normal through early childhood (3-5 yrs) • Hodgkin lymphoma rare before 10 yo • Consider STDs in adolescents

  6. A Question… • You are evaluating a 6 yo girl who was brought to the office because of R neck swelling and redness of two days duration. She has had fever to 101F and no other recent symptoms, but her mother reports similar previous episodes several times in the past and occasional drainage from the skin in that area. Her PE reveals a 2x2cm erythematous, tender mass just anterior to the SCM muscle. The rest of the PE findings are normal. Which of the following is the most likely diagnosis? • A. Atypical mycobacterial infection • B. Branchial cleft cyst • C. Cystic hygroma • D. Infectious mononucleosis • E. Thyroglossal duct cyst

  7. Size of the Node(s) • Rule of thumb… • Cervical and axillary nodes: 1.0 cm • Inguinal nodes: 1.5 cm • Epitrochlear nodes: 0.5cm • Risk of underlying malignancy increases with increasing size of LN

  8. Location of the Node(s) • Can indicate potential sources of infection • Can prompt an immediate and thorough evaluation, with malignancy high on the differential

  9. Location of the Node(s)

  10. Quality of the Node(s) • Soft, easily compressible, freely mobile • Benign • Tender with associated erythema, warmth, induration or fluctuance • Infection • Hard, firm and rubbery, fixed, matted • MALIGNANCY!!!

  11. Localized vs. Generalized LAD • Localized • More common (Cervical) • Can occur from: • Infection of the node itself • Infection in the node’s drainage area • Generalized • Caused by systemic disease • HSM and rash common

  12. Time Course and Associated Sx • *Biopsy indicated: • No decrease in size of nodes by 4-6 wks • Lack of complete normalization by 8-12wks • Associated features/ symptoms • Exposures? • Animals, uncooked meats, unpasteurized milk • Medications? • Associated constitutional symptoms? • Fever, night sweats, weight loss, pruritis, arthralgias, fatigue

  13. *Differential Diagnosis

  14. Reactive Lymph Nodes • Most common cause of localized enlarged LN in children • Frequent antigenic exposure in early childhood to common childhood illness and the gradual acquisition of antibodies and immunity • Pharyngitis, OM, conjunctivitis cervical LAD

  15. Lymphadenitis • Presentation • Acute onset • Inflamed, enlarged, tender lymph nodes • +/- fever • +/- progression to fluctuation • Most common offending agents: • S. aureus • Group A Streptococcus • Consider anaerobic organisms in older children

  16. Lymphadenitis • *Management • Cultures of drainage or pharyngeal exudate • Antibiotics • Incision and drainage for abscess formation • More indolent causes… • Bartonellahenselae • Mycobacterium tuberculosis • Atypical mycobacteria

  17. A Question… • A previously healthy 12 yo girl comes to your office with the complaint of fatigue for 2 weeks, fever and sore throat for 1 week, and decreased oral intake due to throat pain. Her PE reveals a T101F and otherwise normal VS. She is tired-appearing but nontoxic. Her throat is very erythematous, with copious yellowish tonsillar discharge and she has difficulty swallowing. Several 2x2cm, slightly tender LN are palpable posterior to the SCM muscles bilaterally, and shotty inguinal LAD is noted. Her spleen is palpable 3 cm below the costal margin. The remainder of the PE is normal. Which of the following is the most likely diagnosis? • A. Cat-scratch disease • B. Hodgkin disease • C. Infectious mononucleosis • D. JIA • E. Kawasaki disease

  18. Infectious Mononucleosis • Presentation • Fever • Pharyngitis • LAD (post>anterior cervical) • Fatigue, splenomegaly, malaise, hepatitis, atypical lymphocytosis • Common offending agents • EBV • CMV • HIV

  19. Generalized Lymphadenopathy • Medications • Serum sickness • Carbemazepine, cephalosporins, PCNs, phenytoin, sulfonamides • Malignancy • Leukemia • Lymphoma^ • Autoimmune disease • SLE • JIA • Dermatomyositis

  20. *Diagnostic Evaluation • History and PE • Usually will reveal the cause of the LAD • Useful laboratory tests • CBC • ESR/CRP • LDH • PPD • Specific serologic testing for infectious agents • CXR*

  21. A Question… • A 14 yo boy is referred to the hospital for evaluation of a swollen LN, which his mother says has been growing for the past 6 weeks. The swelling has not improved after 2 weeks of amoxicillin. He has had intermittent low-grade fevers over the last 6 weeks. His PE reveals normal findings, with the exception of a 3x2cm hard, nonmobile LN in the left supraclavicular area. Which of the following tests is most likely to confirm a diagnosis in this patient? • A. Blood culture • B. CXR • C. Excisional biopsy of the node • D. FNA of the node • E. PPD

  22. Lymphoma

  23. Quick Introduction • Third most common childhood malignancy • 12% of the newly diagnosed cancers seen in children <15 yo • 60% of pediatric lymphomas are non-Hodgkin lymphoma • Hodgkin disease accounts for a greater proportion of the lymphomas seen in adolescents

  24. Clinical Presentation

  25. Classification of Lymphoma • Hodgkin disease • Nodular sclerosing • Mixed cellularity • Lymphocyte predominance • Lymphocyte-depleted • Non-Hodgkin lymphoma • Small, noncleaved cell • Burkitt, non-Burkitt subtypes • Lymphoblastic • Large cell

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