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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Origins of Mediastinal Mass Developmental Neoplastic Infectious Traumatic Cardiovascular disorders

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

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

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

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

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

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

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

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

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