Clinico-pathological profile of pediatric lymphadenopathy

OBJECTIVE: To study the clinico-pathological profile of significant pediatric peripheral lymphadenopathy and to arrrive at an etiological diagnosis. METHODS: Prospective study in a tertiary care hospital setting. One hundred consecutive children reporting to pediatric OPD from 1 January 1995 to 31 December 1998, aged 1 month to 12 years were studied. RESULTS: The commonest aetiology diagnosed was tubercular lymphadenitis in 35% cases, followed by chronic tonsillopharyngitis in 15% cases. Lymphomas, AIDS and infectious mononucleosis constituted 3, 2 and 1 cases each. Aetiology could not be ascertained in 44 (44%) children even after detailed haematological, microbiological, radiological and serological investigations. FNAC's sensitivity and specificity as compared to 'gold standard of excision lymph node biopsy was 94% and 100% respectively. CONCLUSION: Tubercular lymphadenitis was the commonest treatable entity of significant pediatric peripheral lymphadenopathy. A majority of the cases even after thorough evaluation, remained undiagnosed. FNAC as a diagnostic modality is almost as sensitive and as specific as excision lymph node biopsy when an adequate aspirate is examined by expert eyes.     

Kikuchi-Fujimoto disease of 16 children in a single center of Korea

Kikuchi-Fujimoto disease (KFD) is subacute necrotizing lymphadenitis characterized by fever, leukopenia and cervical lymphadenopathy. There are few reports on the clinical characteristics and laboratory findings of KFD in the pediatric literature. In this study, we evaluate the characteristics and outcome of KFD in children. A total of 412 patients were studied with fever and peripheral lymphadenopathy at Pusan National University Hospital from January 1998 to December 2003. Among the total 412 there were 16 patients diagnosed with KFD by lymph node biopsy. We analyze the clinical, laboratory and outcome after review of the medical records retrospectively. The mean age of the patients was 10.6 +/- 3.4 yr (range: 4-17 yr). The male to female ratio was 1:1. Almost all patients, except two, had cervical lymph node swelling. The size of the involved lymph node was less than 4 cm in the greatest dimension in 75% of the patients. All the children had fever as the chief complaint and the mean duration of the fever was 17.7 +/- 11.2 days (range: 2-122 days). Approximately 87% of the patients had leukopenia (WBC < 4000/mm(3)) and 43.8% of the patients had a mild increase in the transaminases on liver function testing. A total of 8 out of the 16 patients were initially misdiagnosed as an infectious disease and treated with antibiotics which caused prolonged hospitalization for most patients. Six patients were treated with prednisone and the prolonged fever subsided immediately after steroid therapy. KFD should be considered in the differential diagnosis of prolonged fever in children with cervical lymphadenopathy. Early cervical lymph node biopsy is necessary to minimize inappropriate examinations and treatments in such cases.     

Specific and nonspecific lymphadenitis in childhood: etiology, diagnosis, and therapy

Over a period of 4 years, 39 children with lymphadenitis were treated surgically; in 31 cases cervical lymph nodes were the main location. In 9 cases the lymphadenitis was caused by mycobacterial infection.Staphylococcus aureus was the most frequent causative organism of unspecific lymphadenitis (11 cases). The therapy of choice appears to be surgical treatment and medical care after operation. Especially in mycobacterial lymphadenitis, complete surgical excision of the lymph node is decisive for definitive healing. There was only 1 case of therapy-resistant, relapsing cervical lymphadenitis that needed a second operation. Causative organisms in this case wereMycobacterium avium andMycobacterium intracellulare. All other patients showed an uneventful postoperative clinical course. We believe that a consequent diagnostic process and cooperation between the pediatric surgeon and pediatrician are necessary for effective therapy.     

Mesenteric lymph nodes in children: what is normal?

Background: Enlarged mesenteric lymph nodes (MLN) are frequently seen in children with abdominal pain and, in the absence of other disorders, have been attributed to primary mesenteric lymphadenitis. Objective: To evaluate the prevalence of enlarged MLN (short axis 5 mm) as detected by abdominal CT in children with a low likelihood for mesenteric lymphadenopathy. Materials and methods: During a 14-month period, we identified all non-contrast abdominal CT examinations performed at a tertiary care pediatric hospital for evaluation of suspected or known renal stones. Two radiologists reviewed the examinations and recognized all enlarged MLN, measured the short-axis diameter, and noted the quadrant location. Results: Sixty-one children were identified who met entry criteria; mean age was 10.7 years (range 1.1–17.3 years). Enlarged MLN were found in 33 (54%) of the 61 children; the largest enlarged MLN was most frequently in the right lower quadrant (RLQ) (29 of 33, 88%). Seventeen of the 61 children (28%) had three or more enlarged MLN; all were in the RLQ. The largest short-axis diameter measured was 10 mm. Summary: MLN with a short-axis diameter of >5–10 mm are commonly found on abdominal CT examination of children with a low likelihood for mesenteric lymphadenopathy and should be considered a non-specific finding. A short-axis diameter of 8 mm might better define the upper limit of normal mesenteric lymph node size in children.     

Peripheral lymphadenopathy in children in Dar es Salaam, Tanzania. A study from biopsy material

Children are commonly brought to the primary physician because of palpable peripheral lymph nodes. In order to determine the common causes 257 excisional peripheral lymph node biopsies of children between four days and 15 years of age were analysed. The diagnoses made were: tuberculous lymphadenitis (67.3%), non-specific reactive lymphadenitis (20.6%), malignant neoplasm (11.3%) and histiocytosis-X (0.8%). Fifty percent of the children with tuberculous lymphadenitis were less than five years of age. Of the neoplasms Hodgkin's disease was the commonest (34.5%).     

Assessment of peripheral lymphadenopathies: experience at a pediatric hematology-oncology department in Turkey

Since a large variety of disorders may lead to lymph node enlargement determining the cause of peripheral lymphadenopathy (LAP) in children can be difficult. This retrospective study evaluated 200 children who were admitted to an Oncology-Hematology department because of lymphadenopathy and aimed to determine the clinical and laboratory findings that were valuable for differential diagnosis. A specific cause for lymphadenopathy was documented in 93 (46.5%) cases. One hundred forty (70%) children were classified as having a benign cause for lymph node enlargements. Fourteen (10%) of these cases underwent an excisional lymph node biopsy, and histopathological examination showed a reactive hyperplasia. Sixty (30%) cases were classified as having a malignant disease-causing lymphadenopathy. In terms of differential diagnosis, some associated systemic symptoms, physical findings, and laboratory investigations showed significant difference between benign and malignant lymphadenopathy groups. The following findings were determined as being important to alert the physician about the probability of a malignant disorder: location of the lymphadenapathy (supraclavicular and posterior auricular), duration of the lymph node enlargement (>4 weeks), size of the lymph node (>3 cm), abnormal complete blood cell findings, abnormalities in chest X-ray, and abdominal ultrasonography.     

ASSESSMENT OF PERIPHERAL LYMPHADENOPATHIES: Experience at a Pediatric Hematology-Oncology Department in Turkey

Since a large variety of disorders may lead to lymph node enlargement, determining the cause of peripheral lymphadenopathy (LAP) in children can be difficult. This retrospective study evaluated 200 children who were admitted to an Oncology-Hematology department because of lymphadenopathy and aimed to determine the clinical and laboratory findings that were valuable for differential diagnosis. A specific cause for lymphadenopathy was documented in 93 (46.5%) cases. One hundred forty (70%) children were classified as having a benign cause for lymph node enlargements. Fourteen (10%) of these cases underwent an excisional lymph node biopsy, and histopathological examination showed a reactive hyperplasia. Sixty (30%) cases were classified as having a malignant disease-causing lymphadenopathy. In terms of differential diagnosis, some associated systemic symptoms, physical findings, and laboratory investigations showed significant difference between benign and malignant lymphadenopathy groups. The following findings were determined as being important to alert the physician about the probability of a malignant disorder: location of the lymphadenopathy (supraclavicular and posterior auricular), duration of the lymph node enlargement (> 4 weeks), size of the lymph node (> 3cm), abnormal complete blood cell findings, abnormalities in chest X-ray, and abdominal ultrasonography.     

Non-tuberculous mycobacterial lymphadenitis in children

Eighty-six children (44 males, 42 females) were identified as having non-tuberculous mycobacterial lymphadenitis. The diagnostic criteria were either culture of the organism from the affected lymph node (n=68), or, when culture was negative, a positive skin test with non-tuberculous mycobacterial antigens and negative skin test responses to tuberculin purified protein derivative (PPD) in association with typical histological features (n=18). All children had histopathological findings of granulomatous inflammation with caseation and/or acid-fast bacilli. Eighty-two percent of the children were under 5 years of age at presentation and 30% were less than 2 years old. Most (79%) were city dwellers. Lymph node enlargement had been present for less than 6 months in almost all children (97.5%) and was almost exclusively in the face and neck region (97%). Disease was confined to the involved lymph nodes in 56% but had extended beyond the confines of the infected node to form a collar stud abscess in 38% and 6% presented with a skin sinus. Extranodal extension did not show any statistically significant association with the duration of lymphadenopathy. The duration of lymphadenopathy had been greater in those children in whom an organism was not isolated on culture resected tissue ², P<0.01). All children were treated surgically, and recurrence occurred in five patients. This study describes the clinical and demographic characteristics of non-tuberculous mycobacterial lymphadenopathy in children in a population in which tuberculous adenitis is rare. Recognition of these features may allow earlier diagnosis and appropriate surgical therapy.Abbreviation PPD purified protein derivative     

Peripheral lymphadenopathy in childhood--recommendations for diagnostic evaluation

BACKGROUND: Enlargement of peripheral lymph nodes most commonly caused by a local inflammatory process is frequently seen in childhood. The aim of the present study was to analyze the most common causes of peripheral lymphadenopathy and to develop a simple algorithm for the primary diagnostic evaluation of peripheral lymph node enlargement in this age group. PATIENTS: Between April and September 1999 87 unselected children (median age: 5 1/2 years) with peripheral lymphadenopathy were referred to the Department of Pediatrics, University of Graz, for further investigation. RESULTS: EBV infection was diagnosed in 20 (23.0%) children. 19 (21.8%) patients had acute bacterial lymphadenitis. In 21 (24.1%) patients lymph node enlargement was classified as "post/parainfectious (viral)". Four patients each had toxoplasmosis and cat scratch disease. In 11 (12.6%) patients neither physical nor laboratory examinations revealed pathologic results. Among the remaining 8 children sarcoidosis and Hodgkin disease was diagnosed in one patient each. Small, soft, mobile, nontender, cervical, axillary or inguinal lymph nodes do not require further investigations. In case of enlarged, tender lymph nodes with overlying skin erythema and fever diagnostic evaluation should include complete blood count, erythrocyte sedimentation rate and/or c-reactive protein level, supplemented by appropriate antibody testing (EBV, CMV, Toxoplasma gondii, Bartonella henselae). Firm, enlarged, painless lymph nodes which are matted together and fixed to the skin or underlying tissues necessitate a more detailed diagnostic evaluation in order to exclude malignant or granulomatous diseases. CONCLUSIONS: Our study demonstrated that primary diagnostic evaluation of childhood peripheral lymphadenopathy is mainly based on clinical grounds. In most cases a small number of additionally performed laboratory tests allow to correctly identify the cause of the peripheral lymph node enlargement.     

Solid tumors of childhood

Objective : Cancer is one of the leading causes of death in children. There is the need to have the histologic review of malignancies in children from the Indian sub–continent.Methods : In the present study, malignant tumors received over 12 years were reviewed and re–classified according to classifications based on prognosis.Results : A total of 472 tumors were received over 12 years. Of these 318 were benign and 154 malignant. The commonest malignant solid tumor was lymphoma followed by pediatric renal tumors. The sarcomas included bone tumors, Rhabdomyosarcoma and synovial sarcoma. There were 13 germ cell tumors, 10 retinoblastomas and six neuroblastomas.Conclusion: The review revealed that a definite diagnosis or classification was not assigned in 21 cases in the original reporting. Of these 14 could be assigned a definite category on review and immuno-staining. These included five non-Wilms sarcomas, four Rhabdomyosarcomas, three Ewing’s sarcoma/ PNETs and two Synovial sarcomas. The study also revealed an unexpected high percentage (11%) of epithelial malignancies in children     

Nontuberculous mycobacterial infections of the head and neck

Nontuberculous mycobacteria are ubiquitous in the environment. Immunocompetent children are commonly infected by these resilient organisms. Cervical lymphadenitis, the most frequent head and neck manifestation of NTM infection, often presents as chronic, unilateral lymphadenopathy with characteristic violaceous overlying skin changes. Diagnosis is ultimately dependent on culture or histopathologic examination of specimen obtained through excisional lymph node biopsy or FNA. The principal treatment of NTM infection remains the surgical excision of diseased tissue. Antibiotics augment surgical therapy and their potential role as a single-modality therapy continues to be investigated.     

亚急性坏死性淋巴结炎33例

目的 探讨儿童亚急性坏死性淋巴结炎(SNL)的病因及，临床特征，提高对儿童SNL的认识，减少误诊。方法 结合文献资料对SNL患儿33例临床及实验室相关检查进行回顾分析。结果 本组33例患儿淋巴结活检确诊SNL；发病以学龄儿为主，2／3患儿冬春季节发病，男女之比3.7：1；均有淋巴结大，发热32例，白细胞总数减少21例；其中1例发展为系统性红斑狼疮，1例复发。结论 对不明原因发热伴淋巴结大者，除做相关化验检查外，应早期行淋巴结活检以明确诊断。SNL是自限性疾病，预后多良好，但也有复发。少数发展为系统性红斑狼疮，应长期随访。     

Skin manifestations of Kikuchi-Fujimoto disease: case report and review

Kikuchi-Fujimoto disease (KFD) is a histiocytic necrotising lymphadenitis, which is a benign disease of unknown aetiology. Misdiagnosing KFD as lymphoma or systemic lupus erythematosus is not uncommon due to the similarity of clinical and histopathological features of these diseases. A 12-year-old female suffered from cervical lymphadenopathy, leukocytopenia, fever and especially skin rash. The biopsy of the lymph node was compatible with KFD. The skin biopsy showed interface alterations with vacuolar degeneration of the basal cells suggesting lupus erythematosus; however, the patient did not fulfill the diagnostic criteria for systemic lupus erythematosus. After treatment with acetaminophen, fever subsided and the skin rashes disappeared without relapse during a 10-month follow-up period. Conclusion: the histopathological findings of cutaneous lesions in KFD are usually similar to those observed in the involved lymph nodes. This report suggests that interface change might be one of the pathological features of the cutaneous manifestations of KFD.Abbreviations KFD Kikuchi-Fujimoto disease - SLE systemic lupus erythematosus     

High prevalence of antibodies against Bartonella henselae with cervical lymphadenopathy in children

Background: Cat‐scratch disease is the most common form of Bartonella henselae infection. Although reports have shown that CSD is relatively common, they have not shown the prevalence of seropositivity for Bartonella henselae in cases of cervical lymphadenitis and Kawasaki disease, which are relatively common diseases in children. Methods: We evaluated the presence of immunoglobulin (Ig) G‐ and IgM‐class antibodies against Bartonella henselae in children with cervical lymphadenitis, Kawasaki disease, and infectious diseases without lymphadenopathy in a semi‐rural area in Japan. Results: We found that the positivity rate for the IgG antibody against Bartonella henselae in patients with cervical lymphadenitis who owned cats or dogs was significantly higher than that in patients with Kawasaki disease and infectious diseases without lymphadenopathy. However, the average age of children with cervical lymphadenitis did not significantly differ when compared to those with other infectious diseases. Conclusion: Our serological study showed that Bartonella henselae infection may contribute to the etiology of cervical lymphadenitis in children.     

Comparison of ultrasound with plain radiography and CT for the detection of mediastinal lymphadenopathy in children with tuberculosis

Background: Lymphadenopathy, with or without parenchymal abnormality, is the radiological hallmark of primary tuberculosis (TB) in children. However, lymph node enlargement may pass undetected on plain chest radiographs. Ultrasonography provides complementary information to that obtained by radiographs. Objective: To assess the clinical value of US for the detection of mediastinal lymphadenopathy in children with a positive intradermal tuberculin test. Materials and methods: Thirty-two children with a mean age of 6 years and a positive Mantoux test underwent chest radiography (frontal and lateral) and US (suprasternal and left parasternal access routes). Chest CT was performed at the discretion of the attending physician in six cases. Results: Eleven children had clinical symptoms and 90% a recent contact with a person with active TB. In 90.5% of children with chest radiographic images compatible with TB, coincident findings in the mediastinal US study were found. By comparison, 66.7% of those with normal chest radiography had evidence of mediastinal lymphadenopathy on the US scan. In all cases but one, US and CT findings agreed. Conclusions: Mediastinal US is useful for the detection of enlarged lymph nodes in children with a positive tuberculin reaction and normal chest radiography.     

Analysis of the interleukin-12/interferon-γ pathway in children with non-tuberculous mycobacterial cervical lymphadenitis

Genetic defects along the interleukin (IL)-12/interferon (IFN)−γ pathway have been found in patients with mendelian susceptibility to mycobacterial disease (MSMD) caused by live BCG vaccine or non-tuberculous Mycobacterium (NTM) species, highlighting the crucial role of this axis in human immunity to Mycobacterium. The aims of this study were to characterize healthy children presenting with cervical lymphadenitis caused by NTM and to investigate their IL-12/IFN-γ pathway. Epidemiological, clinical, laboratory and pathological findings were reviewed retrospectively. Blood samples from five patients and healthy controls were in vitro activated with BCG, BCG + IL-12 and BCG + IFN-γ and levels of IL-12p40 and IFN-γ were measured. Fourteen patients (11 males, median age 24 months, range 12–78 months) were studied. The mean duration of illness before diagnosis was 9.1 weeks. Mycobacterium tuberculosis purified protein derivate (PPD) was positive in all patients (mean 14.5 ± 9.8 mm). Caseous granuloma was found in all ten patients who underwent excision biopsy. However, acid fast stain was positive in only five children and cultures were positive in only three cases. The amplified M. tuberculosis direct test was negative in all tested cases. No significant differences in IL-12p40 and IFN-γ levels were found between patients and controls. In spite of the normal response as measured in the screening test, it is still possible that patients might have a monogenic/mendelian disease for which the genetic defect(s) have yet to be elucidated. Alternatively, some single nucleotide polymorphisms along the IL-12/IFN-γ axis might be associated with an isolated cervical lymph node infection and not a disseminated disease in children.     

Nontuberculous mycobacterial lymphadenitis in children

OBJECTIVES: To describe the clinical and epidemiologic features, management and outcome associated with the development of nontuberculous mycobacterial (NTM) superficial lymphadenitis in children. METHODS: The medical records of all children 0 to 14 years of age with NTM superficial lymphadenitis who were diagnosed at P. and A. Kyriakou Children's Hospital between January, 1982, and December, 1997, were reviewed. RESULTS: Forty-seven children were identified, 76.5% during the second half of the study period. Mycobacterium avium complex was the predominant isolate. Children with NTM lymphadenitis noted satisfactory aesthetic results when total excision was performed within 1 month after its onset. CONCLUSIONS: NTM superficial lymphadenitis in children has been increasingly recognized during the last decade. Prompt total excision of the involved lymph node is required in such patients.     

Needle localization of small pediatric tumors for surgical biopsy

Background. Small pediatric tumors may be difficult to biopsy or resect. Objective. To examine the benefits of needle localization of a variety of small pediatric tumors before surgical biopsy or excision. Materials and methods. Seven patients aged 1–19 years underwent 12 procedures for needle localization of suspected tumor. Two patients had undergone previous biopsies without needle localization with negative results. Computed tomography (four patients) or ultrasonography (three patients) guided needle placement. Each patient had suspected tumor(s) in 1–3 anatomical sites, including thigh (7), lung (2), parasacral region (2), and iliac bone (1). Results. All 12 lesions (9 less than 1 cm³ in volume) were successfully localized for excision or biopsy. Three small (<1 cm³) soft-tissue lesions (two ganglioneuroblastomas and one ganglioneuroma) were excised from one patient, a 0.65-cm³ residual soft-tissue sarcoma from another; and recurrent bilateral teratomas from a third. Two peripheral primitive neuroectodermal tumors were excised with positive margins from a fourth patient. Two lesions contained only fibrosis, as determined by histopathology. Two other patients underwent thoracoscopic removal of lung metastases that were less than 0.1 cm³. Conclusion. Needle localization allows effective and less invasive excision or biopsy of a variety of small pediatric soft-tissue lesions. Received: 5 August 1999 Accepted: 7 December 1999     

Outcome of parapneumonic empyema

Objective: Empyema thoracis is known to have variable age group affection, causative agents and controversy regarding primary mode of management. To look into current demography, bacteriology and treatment outcome.Methods: Prospective study made on admitted cases of parapneumonic empyema from July 2001 to June 2003. All cases were treated with chest tube drainage, parenteral antibiotics or thoracotomy in multiloculated or non-improving cases.Results: 0.8% (C.I. 0.6–1.0) of total pediatric admission had empyema, who were more likely to be females (P<0.05), under-weight (P<0.05) compared to children admitted for other reasons.Staphylococcus aureus is still the commonest isolate (13.2%). All cases received antibiotics prior to hospitalisation. Majority of cases (90.5%) could be successfully managed with antibiotics and chest tube drainage alone. 9.4% cases needed thoracotomy. 5.8% cases needed salvage thoracotomy following non-improvement with chest tube drainage. Fever remission time and duration of hospital stay were comparable in both groups. Thoracotomy cases required antibiotics for shorter period (P=0.04). Two cases died due to reasons other than mode of management. Radiological and lung function recovery was excellent in most of the cases.Conclusion: Chest tube drainage is a safe, efficacious primary method of empyema management.