November Week 2: Lymphadenopathy
Case 1:
A 2 yo female is brought in by her mother for a sick visit. Mom reports today she developed fever and a swelling in her right neck. In exam, the patient is tilting her head to the right, and you palpate a warm, tender mass 5 x 5 cm on the anterior margin of the right SCM with erythema of the overlying skin.
What other history would like to know? (exposures to animals, uncooked meats, unpasteurized milk, medications, fever, night sweats, weight loss, pruritus, arthralgias,
fatigue)
What is normal size for cervical lymph nodes? What about axillary and inguinal? (in general, axillary and cervical : up to 1 cm, inguinal up to1.5 cm, epitrochlear up to 0.5 cm)
What is in your differential diagnosis? What is the most likely diagnosis? (lymphadenitis, infected branchial cleft cyst, TB, less likely mono, cystic hygroma, other infectious process)
What organisms are the most common? (staph aureus and GAS)
What is your plan? (course of 1st or 2nd gen cef or diclox, tell mom to return if not improving!)
If the patient does not improve clinically after a course of antibiotics, what else should you think about and what other tests might you order? (CBC, ESR, LDH for marker of heme malign, PPD, monospot, CXR if cough, dyspnea, chest pain, or generalized LAD for mediastinal mass, TB, sarcoid. Bx if not decreased after 4-6 wks or normalized completely in 8-12 wks)
Case 2:
You are seeing a 15 year old male in clinic for a swollen lymph node above his right clavicle. He reports he noticed it about 6 weeks ago and it has been steadily growing. He saw an urgent care 2 weeks ago who gave him a 10 day course of amoxicillin which did not help. He also reports low grade fevers “on and off” for the last several weeks. On exam, you palpate a 3 x 3 cm nontender right supraclavicular lymph node, otherwise exam is normal.
What is your differential diagnosis? (Hodgkins (rare under age 10), anterior mediastinal mass, other malignancy, TB)
What is your next step in work up? (open excisional bx of largest/most abnormal node)
What are other indications for biopsying a lymph node immediately? (supraclavicular node, hard, fixed, or nontender nodes; the absence of related symptoms suggesting infection; fevers lasting longer than 1 week; night sweats; weight loss greater than 10%; abnormal findings on CBC or CXR; elevated ESR)