LYMPHADENOPATHY
History
Munira is a 7-year-old Asian girl who presents to the paediatric rapid referral clinic with a lump on the side of her neck. Her mother noticed it a week earlier. It is not painful. She has had no fevers, night sweats or weight loss. Her mother states that, about 4 weeks ago, she had a cold that lasted for 2 days and was not accompanied by a temperature. Munira had the BCG vaccine when she was a baby. There is no family history or history of contact with TB. There has been no travel in the last 6 months.
Examination
Munira is apyrexial. There is a 4 3 cm lump on the left side of the neck. It is not erythematous, warm or tender. It is mobile and not attached to the skin. There are some small (1 cm) lymph nodes on the right side of the neck. There is no lymphadenopathy elsewhere and no hepatosplenomegaly. A BCG scar is seen. The ear, nose and throat appear normal and there are no signs in the other systems. The child is investigated and reviewed 48 hours later with the results.
INVESTIGATIONS
Normal
Haemoglobin 10.7 g/dL 10.5–13.5 g/dL
White cell count 10.3 109/L 4.0–11.0 109/L
Neutrophils 7.2 109/L 1.7–7.5 109/L
Platelets 430 109/L 150–400 109/L
C-reactive protein (CRP) 12 mg/L 6 mg/L
Erythrocyte sedimentation rate (ESR) 24 mm/hr 0–15 mm/hr
Anti-streptolysin O titre (ASOT) 200 IU/ml 200 IU/ml
Paul–Bunnell test Negative
Chest X-ray Normal
Neck ultrasound – several enlarged lymph nodes seen, the largest 2.2 cm in diameter.
No fluid collection seen
Mantoux test (read at 48 hours) – negative
Questions • What is the differential diagnosis at presentation (prior to the investigation results)? • Would you administer any treatment at the first visit? • What is the most likely diagnosis following the investigation results? • What course of action would you follow if there was no change in the size of the lump after 10 days?
Medicine
The lump is consistent with enlarged lymph nodes. The differential diagnosis is:
• infection – bacterial, viral or mycobacteria (tuberculosis and non-tuberculous mycobacteria)
• malignancy – lymphoma or leukaemia. Lymph nodes are often palpable in children. Cervical and axillary lymph nodes 1 cm in diameter and inguinal lymph nodes 1.5 cm in diameter are considered to be enlarged. Any enlargement in any other lymph nodes, e.g. supraclavicular, requires further investigation. All children get several upper respiratory tract infections a year, and the minor cold several weeks earlier is probably irrelevant. Statistically, a bacterial cervical lymphadenitis is the most likely diagnosis. However, usually there is a clear history of a current or recent upper respiratory tract infection. In bacterial infections, the overlying skin is usually erythematous and the lump is warm and tender. Occasionally the swelling may become fluctuant and this is indicative of pus formation and an abscess. In such a case, a referral should be made to a surgeon for incision and drainage. In viral infections, the nodes are tender but are not usually warm or erythematous. The Paul–Bunnell test is similar to the Monospot test and is a test for glandular fever. Viral serology for HIV, cytomegalovirus, toxoplasmosis (which often produce more generalized lymphadenopathy) and cat scratch disease (due to Bartonella henselae) would be helpful if there was still no diagnosis after the initial investigations. In tuberculosis, the lump is cold and non-tender. Munira has had her BCG vaccination but it is important to remember that, although this vaccination provides reasonable protection against miliary TB and TB meningitis (50–80 per cent), it only provides 50 per cent protection for pulmonary TB and only minimal (if any) protection against non-tuberculous mycobacteria. A lymphoma can present with non-tender cervical lymphadenopathy. The lymph nodes tend to be firmer than inflammatory nodes and may be adherent to the overlying skin or underlying structures. The absence of systemic symptoms, such as fevers, night sweats and weight loss, makes the diagnosis of tuberculosis and lymphoma less likely. At the first visit, it would be worth giving a 10-day course of an antibiotic, e.g. coamoxiclav, that would treat streptococcal and staphylococcal infection. This would treat the most likely diagnosis of a bacterial lymphadenitis. The white blood cell count is normal and the CRP and ESR are only mildly elevated. The ASOT, Paul–Bunnell test and Mantoux are negative. These results make an infection unlikely and a malignancy the most likely diagnosis. If there was no diminution in the size of the lump following the 10-day course of treatment (which would suggest that the diagnosis is not a bacterial lymphadenitis), the patient should be referred to a surgeon for an urgent biopsy. This was the case with Munira in whom the lymph node biopsy was diagnostic of Hodgkin’s lymphoma.
KEY POINTS
• Most children have some small palpable lymph nodes.
• The commonest cause of cervical lymphadenitis is streptococcal or staphylococcal infection.
• Patients with lymphoma commonly present with non-tender firm cervical lymphadenopathy
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