“Approach To Lymphadenopathy” from Peds Cases

Here are links to and excerpts from Approach To Lymphadenopathy by Anna.Whalen-Browne Feb 15, 2017 from Peds Cases:

To see a listing of categories click here: Categories [The Table Of Contents of Peds Cases].

Here is the link to the Script of this episode.

And here are excerpts:

Approach to Lymphadenopathy

Developed by Anna Whalen-Browne and Dr. Melanie Lewis for PedsCases.com. February 15, 2017.

Attention to lymph nodes is important to almost all medical specialties in both adult and pediatric medicine. Not only can lymph node characteristics help us decipher possible underlying pathologies, but changes in these glands can also tip us off that there may be more worrisome sinister disease going on.

On the other hand, it is important to note,
particularly when assessing the pediatric population, that up to half of otherwise healthy children may have palpable lymph nodes on examination (2).

Therefore, in this podcast, we will discuss what lymph node characteristics elicited on history and physical examination should make us more or less worried.

[First], we want to learn more details about the patient and their presenting complaint. To this end, we must first gather information on the lymphadenopathy. Specifically, it is important to determine the number, location, onset, duration, quality, growth/evolution/fluctuations, pain or tenderness of the nodes as well as changes to the overlying skin.

Secondly, it is equally important to gather a thorough history of the patient’s health status otherwise. This includes demographics such as the patient’s age, known medical conditions, and recent or concurrent illnesses including upper
respiratory tract infections, infections of the gums, mouth, or teeth, respiratory symptoms such as cough and shortness of breath, skin infections, and sexually transmitted infections if the patient is sexually active.

In order to get a full picture of what could be contributing to the lymphadenopathy, it is also important to do a comprehensive review of symptoms*.

*  See Guide to the Comprehensive Pediatric H&P Write Up from The University Of Central Florida College Of Medicine. The Review Of Systems questions are on pp 4 + 5 of the 15 page PDF.

Ask about fatigue, unintentional weight loss, night sweats, fever, bleeding or bruising, joint/bone pain or swelling, and rash. Finally, as with any clinical presentation, it is important to review all other aspects of the patient’s
history such as recent travel history, exposure to animals including pets, possible exposure to tuberculosis, recent immunizations, current or recent medications, and past
medical, surgical, and family history including solid or hematologic malignancies.

Physical Examination

Next, it is crucial to perform a thorough physical examination of the child. Start with general appearance. Note whether the patient appears well or ill, and assess vital signs. Ensure to always also check growth parameters in pediatric patients including height, weight, and head circumference in infants.

Examine for lymphadenopathy all areas with regional lymph nodes including the neck, axilla, epi-trochlear area, and groin. Record the location and number of regions, size, fixation, tenderness, and consistency of lymphadenopathy, as well as changes to overlying skin including swelling, erythema or
induration.

Examine the head and neck for scalp infection, conjunctivitis, dental caries, mouth ulcers, pharyngitis, tonsillitis, rhinitis, or other.

Thoroughly examine the child’s skin for rashes, infection, petechiae, purpura, or eccymoses. Finally, perform a cardiovascular exam, a pulmonary exam listening and percussing for areas of consolidation, an abdominal examination specifically looking for any palpable masses or hepatosplenomegaly, and a joint exam looking for any arthritis.

Classification Systems [For Lymphadenopathy]

Through both history and physical examination, you first must work to determine whether the lymphadenopathy is localized, meaning confined to one region of the body, or generalized, meaning there are detectable lymph nodes in 2 or more regions of the body (3). With this information, it is possible to narrow your differential significantly, and further rank your patient’s differential within one of these two broad categories.

Next, it is important to establish a timeline of the lymphadenopathy in order to further classify the presentation as acute, subacute, or chronic. We define acute lymphadenopathy as a presentation fewer that two weeks in duration, while subacute describes presentations between 2-6 weeks in duration, and chronic lymphadenopathy being greater than 6 weeks in duration (2). This division, again, can significantly help narrow your differential diagnosis for a specific presentation of lymphadenopathy, and
can help in the interpretation of the rest of the findings on history or physical examination.

The final major classifier when dealing with a presentation of lymphadenopathy is the presence of associated signs and symptoms, specifically fever and splenomegaly.

Based on the categories above which classify the lymphadenopathy as either localized or generalized, acute or subacute or chronic, and with the absence or presence of either
fever or splenomegaly, it is possible to follow a particular path in terms of further questions and investigations in order to ultimately lead us to a specific diagnosis or etiology.

However, although the three aforementioned classification systems can be of significant help in guiding us down a particular path towards a cause of this presentation, it is
important to remember that many of the additional clues that can help in deciphering each clinical presentation of lymphadenopathy must still be gained by a thorough history
and physical examination.

Investigations

Determining which investigations will be most high yield for pediatric patients presenting with lymphadenopathy can be challenging, and must be done with heavy reliance on
one’s clinical reasoning.

Lymph node characteristics that may deter us from pursuing
aggressive investigations include lymph nodes being few in number, localized, less than 1 cm in size, acute in onset, mobile, tender to palpation, and unassociated with changes to overlying skin, or associated with infectious symptoms such as rhinorrhea, otalgia, and cough.

The Centor Criteria can help us determine whether patients presenting with sore throat and lymphadenopathy require further investigation for Strep. pharyngitis infection, or even empiric antibiotic treatment pending culture confirmation(4).

If many low risk features of lymphadenopathy are present, the most important step is to ensure proper patient follow-up to evaluate for changes, progression, or persistence of
lymphadenopathy as well as onset of new symptoms.

If high-risk features dominate in a presentation of pediatric lymphadenopathy, one should consider more aggressive investigations sooner in the course of disease. Such worrisome symptoms include lymphadenopathy that is generalized, subacute or chronic, fixed, non-tender to palpation, associated with changes in the overlying skin, or with certain additional symptoms such as fever, weight loss, night sweats, joint or bone
pain, or splenomegaly.

Such investigations include a complete blood count with differential (CBC-diff), peripheral blood smear, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and liver function tests (LFTs). Depending on the clinical history and
examination, it may also be appropriate to perform culture and sensitivity for bacterial causes such as Streptococcal pharyngitis, or serologic investigations for other infections
such as Epstein-Barr virus (EBV) which causes infectious mononucleosis, and Borrelia burgdorferi which causes Lyme disease. Testing may also be warranted for Mycobacterium species, which can include either a tuberculin skin test or interferon blood test. Chest radiography may also be included to evaluate for mediastinal lymph nodes or pulmonary disease, a step that is particularly important in any child presenting
with lymphadenopathy and respiratory symptoms.

Based on exposure history and specific signs and symptoms, testing for rare infectious causes of lymphadenopathy may also be warranted in certain cases. This could include investigations for Bartonella henselae which causes cat-scratch disease, toxoplasmosis, cytomegalovirus (CMV), brucellosis, syphilis, human immunodeficiency virus (HIV), tularemia, histoplasmosis, or coccidiomycosis.

Ultrasonography including Doppler may also be performed in cases of lymphadenopathy in which there is one specific worrisome node or group of nodes. This can be used to assess whether the palpable mass is of soft-tissue origin, an abscess
that would require incision and drainage, or from inflammatory or malignant causes.

Ultimately, an excision biopsy may be required to definitively rule out a neoplastic cause in a child positive for high-risk features on early investigations, or with otherwise inconclusive investigations but worrisome clinical features.

 

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