Pediatric Cervical Lymphadenopathy

Oral manifestations in pediatric patients with leukemia: A systematic review and meta-analysis

BACKGROUND

Leukemia is the most common malignancy in pediatric patients, and it has extramedullary involvement. Oral manifestations have been reported in the literature, but to the authors' knowledge, no systematic review has presented the general prevalence of these manifestations. This review aimed to determine the prevalence of oral manifestations in pediatric patients with leukemia.

TYPES OF STUDIES REVIEWED

The authors conducted a search of PubMed-MEDLINE, Embase, Latin American and Caribbean Health Sciences Literature, Web of Science, and Scopus. Additional searches were carried out in the gray literature and via hand searching of reference lists of included studies. The inclusion criteria were observational studies that investigated the prevalence and occurrence of oral lesions in pediatric patients with leukemia. Two independent reviewers collected data from the selected articles in a prepiloted Excel (Microsoft) spreadsheet.

RESULTS

From 67 included studies, 79 oral manifestations were reported. The most frequent alteration in children with acute lymphoblastic leukemia during the treatment were caries (81%), with moderate certainty of evidence. The prevalence of gingivitis was 73%, oral mucositis was 50%, and lymphadenopathy was 45%, with very low certainty of evidence. After the therapy, the prevalence of dental anomalies was 61%, and the most common were enamel hypoplasia (40%), dental agenesis (22%), and microdontia (22%), presenting very low certainty of evidence. The high heterogeneity among studies contributed significantly to reduce the certainty of the evidence.

PRACTICAL IMPLICATIONS

The findings of this study show that pediatric patients with leukemia have oral manifestations predominantly during and after treatment. Health care professionals must be aware of oral manifestations and refer the patients to dentists during the oncological treatment. Thus, the dentist must support pediatric patients with leukemia to help ensure a better quality of life.

Outcomes of Referrals in Pediatric Patients With Peripheral Lymphadenopathy

Lymphadenopathy is a common reason for referral to a subspecialist, which may result in significant anxiety for parents. Understanding which patients require a subspecialty referral for lymphadenopathy is key to streamlining health care utilization for this common clinical entity. This is an IRB-approved retrospective study examining pediatric patients consecutively referred to pediatric hematology oncology, otolaryngology, or surgery for lymphadenopathy from 2012 to 2021 at a free-standing tertiary-care children's hospital. Logistic regression was fitted to examine the association between the maximum size of the lymph nodes (LN) and a diagnosis of malignancy. The odds ratio, area under the receiver operator curve, sensitivity, and specificity were estimated. We found a significant association between LN size and cancer diagnosis. For every centimeter increase in the maximal dimension of LN, there was an estimated 2.3 times increase in the odds of malignancy (OR=2.3, 95% CI: 1.65-3.11; P <0.0001). The estimated area under the curve (0.84, 95% CI: 0.78-0.90) indicated that LN size correlated well with cancer diagnosis. A LN cut-off size of 2 cm resulted in an estimated sensitivity of 1.0 (95% CI: 0.87-1.00) and specificity of 0.54 (95% CI: 0.46-0.61). Maximum LN size may be a predictor of malignancy among pediatric patients with lymphadenopathy.

Using T2-weighted magnetic resonance imaging-derived radiomics to classify cervical lymphadenopathy in children

BACKGROUND

Cervical lymphadenopathy is common in children and has diverse causes varying from benign to malignant, their similar manifestations making differential diagnosis difficult.

OBJECTIVE

This study aimed to investigate whether radiomic models using conventional magnetic resonance imaging (MRI) could classify pediatric cervical lymphadenopathy.

METHODS

A total of 419 cervical lymph nodes from 146 patients, and encompassing four common etiologies (Kikuchi disease, reactive hyperplasia, suppurative lymphadenitis and malignancy), were randomly divided into training and testing sets in a ratio of 7:3. For each lymph node, 1,218 features were extracted from T2-weighted images. Then, the least absolute shrinkage and selection operator (LASSO) models were used to select the most relevant ones. Two models were built using a support vector machine classifier, one was to classify benign and malignant lymph nodes and the other further distinguished four different diseases. The performance was assessed by receiver operating characteristic curves and decision curve analysis.

RESULTS

By LASSO, 20 features were selected to construct a model to distinguish benign and malignant lymph nodes, which achieved an area under the curve (AUC) of 0.89 and 0.80 in the training and testing sets, respectively. Sixteen features were selected to construct a model to distinguish four different cervical lymphadenopathies. For each etiology, Kikuchi disease, reactive hyperplasia, suppurative lymphadenitis, and malignancy, an AUC of 0.97, 0.91, 0.88, and 0.87 was achieved in the training set, and an AUC of 0.96, 0.80, 0.82, and 0.82 was achieved in the testing set, respectively.

CONCLUSION

MRI-derived radiomic analysis provides a promising non-invasive approach for distinguishing causes of cervical lymphadenopathy in children.

Suprasternal dermoid sinus: A case report

INTRODUCTION

Congenital anomalies in the neck region, such as dermoid sinuses, pose diagnostic challenges in pediatrics. Surgical excisions are vital to prevent complications.

PRESENTATION OF CASE

A 7-month-old male infant had presented with a congenital suprasternal dermoid sinus, which had been evident since birth. Imaging confirmed the diagnosis, prompting surgical intervention under general anesthesia. A delicate excision was performed, guided by a methylene blue dye injection, followed by histopathological confirmation.

DISCUSSION

Dermoid sinuses typically manifest as cutaneous pits or sinus tracts, with a left-sided predominance and a female predilection. An accurate diagnosis relies on clinical examination and imaging studies to delineate the anomaly. Surgical excision remains crucial to prevent recurrence and complications.

CONCLUSION

This case reaffirms the necessity of prompt and accurate diagnosis followed by surgical intervention for managing congenital dermoid sinuses. Ongoing research and collaborative studies are needed to further refine management strategies and improve outcomes for patients with these anomalies, particularly when presenting in atypical locations.

Management of Persistent Low-Suspicion Cervical Lymphadenopathy in Pediatric Patients

INTRODUCTION

Cervical lymphadenopathy in children is typically self-limited; however, the management of persistent lymphadenopathy remains unclear. This study aimed to evaluate the management and outcomes of patients with persistent cervical lymphadenopathy.

METHODS

Single-institution, retrospective review of children <18 years undergoing ultrasound (US) for cervical lymphadenopathy from 2013 to 2021 was performed. Patients were stratified into initial biopsy, delayed biopsy, or no biopsy groups. Clinical characteristics and workup were compared, and multivariate analyses were performed to assess predictors of delayed biopsy.

RESULTS

568 patients were identified, with 493 patients having no biopsy, 41 patients undergoing initial biopsy, and 34 patients undergoing delayed biopsy. Presenting symptoms differed: no biopsy patients were younger, were more likely to present to the emergency department, and had clinical findings often associated with acute illness. Patients with USs revealing abnormal vascularity or atypical architecture were more likely to be biopsied. History of malignancy, symptoms >1 week but <3 months, and atypical or change in architecture on US was associated with delayed biopsy. Patients with long-term follow-up (LTF) were followed for a median of 99.0 days. Malignancies were identified in 12 patients (2.1%). All malignancies were diagnosed within 14 days of presentation, and no malignancies were identified in LTF.

CONCLUSIONS

Patients with persistent low suspicion lymphadenopathy are often followed for long durations; however, in this cohort, no malignancies were diagnosed during LTF. We propose an algorithm of forgoing a biopsy and employing primary care surveillance and education, which may be appropriate for these patients in the proper setting.

Back to the basics-risk factor identification of pediatric malignant lymphadenopathy proven by pathological studies

PURPOSE

Lymphadenopathy (LAP) is a common problem in the pediatric patient. History, physical examinations (PE), ultrasounds, and blood tests were often obtained while studying such lesions. Malignancy should be highly suspected in certain conditions. This study evaluates the relationship between malignant LAP and risk factors for pediatric patients.

MATERIALS AND METHODS

Medical records of matched patients are reviewed, and data are retrospectively collected. History, PE findings, laboratory data, ultrasound findings, and pathological findings were recorded and analyzed. The median values (interquartile range, IQR) were expressed for continuous variables, and the number of patients (percentage) for categorical variables. Comparisons between groups were performed using the Mann-Whitney U test and the chi-squared test. The significance was set as p value < 0.05.

RESULTS

A total of 142 pediatric patients underwent a biopsy in our department for LAP from July 2004 to August 2021. Among them, 108 (76.1 %) patients had benign lesions, and 34 (23.9 %) had malignancies. Weight loss, fixed LAP, firm consistency, and serum lactate dehydrogenase (LDH) exceeding 240 U/L were more related to malignant LAP than other risk factors. Multiple regression analysis revealed two independent risk factors. The receiver operating characteristic curve regarding LDH level predicting malignancy revealed a sensitivity of 79.31 % and specificity of 36.51 % by applying the criterion as 230 U/L.

CONCLUSIONS

For pediatric LAP, history-taking and physical examinations remained the most important approaches. Ultrasounds, serum LDH, and other laboratory studies may only provide clues. The cutoff level of LDH revealed low sensitivity and specificity for malignant LAP. With firm LAP, which is fixed, a biopsy for tissue proof should be performed.

Rosai-Dorfmann Disease: A Rare Disease Presenting as a Unilateral Neck Swelling

Rosai-Dorfman disease (RDD) is a rare histiocytic proliferative disorder of unknown etiology. Usually it presents with massive painless cervical lymph node enlargement. Histologically, it shows proliferation of distinctive histiocytic cells that demonstrate emperipolesis in the background of a mixed inflammatory infiltrates. Immunohistochemically, the cells are positive for markers such as CD68 and S100. A 14-year-old boy presented with painless right sided cervical lymphadenopathy without any systemic and other ear, nose, and throat manifestations. The biopsy report of the lymph node showed infiltration of sheets of histiocytes showing emperipolesis with areas of fibrosis and hyalinisation. The sinus histiocytes were strongly positive for S-100 protein. RDD must be considered in the differential diagnosis of massive or multiple lymphadenopathies.

Management of Pediatric Persistent Asymptomatic Cervical Lymphadenopathy

OBJECTIVE

Persistent asymptomatic cervical lymphadenopathy (PACL) is a common outpatient referral diagnosis for pediatric otolaryngologists. Historically, excisional biopsy under general anesthesia has been the gold standard for diagnosis but is associated with some risks. Current literature provides little guidance on less invasive monitoring. Our hypothesis is that the majority of children who present with PACL can be safely monitored with ultrasound and avoid the risks of excisional biopsy.

STUDY DESIGN

A retrospective review was performed of patients <18 years of age, referred to a tertiary care children's hospital for PACL who also underwent at least 1 neck ultrasound from 2007 to 2021. Patients with acute neck infections, congenital masses, or known rheumatologic, immunologic, or malignant conditions were excluded. A multivariate logistic regression model was used to determine patient and nodal factors associated with the decision for operative management.

SETTING

University of California, San Francisco Pediatric Otolaryngology Department.

RESULTS

Among the 197 patients meeting inclusion criteria, 30 (15.2%) underwent surgical biopsy. Overall, 26% underwent repeat ultrasound with a mean interval of 6.6 months, and a mean decrease in nodal size of 0.34 cm. Of the 30 surgical cases, 27 (90%) patients had benign pathology. Multivariate regression analysis revealed pain (p = .04), firmness (p < .001), and lack of a normal fatty hilum on ultrasound (p = .04) as statistically significantly correlated with decisions for surgical management.

CONCLUSION

The majority of pediatric PACL is benign and does not require an excisional biopsy to rule out lymphoma. Serial clinical follow-up with neck ultrasound can be used to safely monitor patients.

Imaging of Pediatric Cervical Lymphadenopathy

There is a wide variety of disease entities in children, which can present with cervical adenopathy. The spectrum of pathology and imaging appearance differs in many cases from that seen in adults. This review aims to compare the strengths and limitations of the various imaging modalities available to image pediatric patients presenting with cervical adenopathy, provide guidance on when to image, and highlight the imaging appearance of both common and uncommon disorders affecting the cervical nodes in children to aid the radiologist in their clinical practice.

Fifteen-minute consultation: A structured approach to the child with palpable cervical lymph nodes

Palpable cervical lymph nodes are common in children and are a frequent reason for presentation to both primary and secondary care. Enlarged lymph nodes are most commonly the result of self-limiting infection, and in children, are rarely the first indicator of a malignant process. This article presents an evidenced-based approach to evaluating these patients.

Association between the Clinical, Laboratory and Ultrasound Characteristics and the Etiology of Peripheral Lymphadenopathy in Children

Peripheral lymphadenopathy affects most children at least once in a lifetime and represents a major reason for concern. Therefore, we aimed to identify the most common causes of peripheral lymphadenopathy in hospitalized children and to determine the clinical, laboratory and ultrasound characteristics that enable fast, easy and accurate etiological diagnosis. We performed a cross-sectional study including 139 children who were hospitalized because of peripheral lymphadenopathy. Ultrasound of lymph nodes was performed in 113 (81.3%) patients. Lymphadenopathy was generalized in nine (6.5%) patients. Malignant etiology was established in only three (2.2%) patients. Bacterial lymphadenitis, infectious mononucleosis (IM) and cat scratch disease (CSD) were diagnosed in 66 (47.5%), 31 (22.3%) and 29 (20.9%) patients, respectively. Bacterial lymphadenitis was significantly associated with neutrophilia (p < 0.01), and increased C-reactive protein levels (p < 0.01). IM was associated with pharyngitis (p < 0.01), leukocytosis without neutrophilia (p = 0.03) and increased blood liver enzyme levels (p < 0.01). CSD was associated with recent contact with a cat (p < 0.01), absence of a fever (p < 0.01) and normal white blood cell count (p < 0.01). Thorough history and clinical examination in combination with a few basic laboratory tests enable fast and accurate differentiation between the most common etiologies of lymphadenopathy in children to avoid unnecessary procedures and hospitalizations.

Evaluation of a Neck Mass in a Six-Month-Old Infant: A Case Report

Pediatric neck masses are one of the commonly encountered problems in clinical practice. They comprise a wide spectrum of congenital to acquired lesions manifesting in early or late childhood. They often pose a diagnostic challenge to the physician. We hereby present a case report of a six-month-old boy with a left-sided neck mass. Findings of a detailed workup were consistent with acute bacterial cervical lymphadenitis, ruling out neoplasia. The child showed significant improvement after including extended coverage of antibiotic therapy for methicillin-resistant Staphylococcus aureus (MRSA) and was put under follow-up.

Ultrasound versus fine needle aspiration for the initial evaluation of pediatric cervical lymphadenopathy-A systematic review

OBJECTIVE

Cervical lymphadenopathy is a frequent finding in children that poses diagnostic challenges. We sought to compare the utility of fine needle aspiration (FNA) with ultrasound (US) for evaluating pediatric cervical lymphadenopathy based on published literature.

STUDY DESIGN

In October 2019, we performed a comprehensive electronic search of PubMed, OVID (MEDLINE), EMBASE, and Scopus databases. Two authors independently screened and assessed full-text reports of potentially eligible studies. We compared sensitivity, specificity, positive predictive value estimates, and balanced accuracy for determining the underlying etiology of lymphadenopathy.

RESULTS

The initial search returned 7736 possible studies, of which 31 met the criteria for inclusion. A total of 25 studies were included in the final analysis, with a total of 4721 patients, of which 52.8% were male. Of these, 9 (36.0%) examined US, and 16 (64%) examined fine needle aspiration. The pooled balanced accuracy for determining etiology was 87.7% for US and 92.9% for FNA. Reactive lymphadenopathy was identified in 47.9%, 9.2% were malignant, 12.6% were granulomatous, and 6.6% were non-diagnostic.

CONCLUSIONS

In this systematic review, US was identified as an accurate initial diagnostic imaging modality in children. Fine needle aspiration was found to play a significant role in ruling out malignant lesions and potentially avoiding excisional biopsy.

Tuberculous and non-tuberculous cervical lymphadenopathy incidence and distribution in Somalia from 2016 to 2020: A review of 241 cases

Objective

To determine the incidence of tuberculous lymphadenitis (TBL) and other pathologies in cervical lymphadenopathies in Somalia and accompanying radiological findings.

Methods

In this hospital-based retrospective study, the demographic characteristics, pathology results and radiological findings of 263 patients who underwent ultrasound (US)-guided cervical lymph node biopsy between January 2016 and February 2020 were analyzed.

Results

Of 241 patients 118 men and 123 women (mean age 27.9 ± 18.1 years) included in the study, 46.1% (n = 111) were diagnosed as necrotizing granulomatous lymphadenitis (caseified, consistent with TBL) and 21.6% (n = 12, atypical lymphoid cells and n = 40, metastases) as malignancy. The most common type of metastasis was squamous cell cancer (n = 31), and the primary source of most of them was esophageal cancer (16/31, 51.6%). The age of patients with TBL was significantly lower than that of non-TBL (21.9 ± 14.6 vs. 41.9 ± 24.6, P = 0.003) and the incidence of TBL in pediatric patients was statistically higher (58.0% vs. 21.5%, P = 0.019). The rate of patients with TBL being localized at level 4 and level 5 was significantly more than non-TBL patients (18.0% vs. 10.0% and 23.4% vs. 10.8%, respectively, P = 0.01). Half of patients with TBL who have chest radiography had pathological findings; consolidation and bronchopneumonia were present in 52.6% of them. There were 2 patients with paravertebral abscess and one patient with gastrointestinal tuberculosis.

Conclusion

In Somalia, in the presence of cervical lymphadenopathy, after diagnosis by using US-guided biopsy; primarily considering of TBL and malignancy, thoracic involvement should be investigated, and esophageal carcinoma must be excluded in terms of metastatic lymph node.

Recurrent Rash in an 11-Year-Old Boy With Pericardial and Pleural Effusions

An 11-year-old, previously healthy boy presented to the emergency center (EC) for acute respiratory distress in the setting of 5 months of recurrent and worsening rash with progressive fatigue, shortness of breath, chest pain, and cough. At the onset of his rash, he and his younger brothers were diagnosed with roseola. Although his brothers' symptoms resolved, the patient's rash recurred, prompting his primary care provider to prescribe amoxicillin. The rash subsequently worsened, so amoxicillin was stopped; a prednisone course was prescribed which alleviated the rash. Upon completion of the prednisone course, the rash returned more diffusely with associated symptoms of shortness of breath, chest pain, and cough. Because of these symptoms, his mother brought him to the EC, where his vitals were notable for tachypnea and tachycardia. His initial EC imaging workup was remarkable for an echocardiogram with a mild to moderate circumferential pericardial effusion, chest x-ray (CXR) with a large right pleural effusion, and chest computerized tomography significant for prominent and diffuse mediastinal and hilar lymphadenopathy with numerous enlarged axillary lymph nodes. Laboratory results were notable for elevated liver enzymes, inflammatory markers, d-dimer, and brain natriuretic peptide. Differential diagnosis remained broad, including infectious, oncologic, and rheumatologic etiologies. Our panel of experts reviews the evaluation, hospital course, and treatment of this patient presenting with an unusual rash and serositis.

The Evaluation of Lymphadenopathy in a Resource-Limited Setting

Lymphadenopathy (LAP) refers to abnormalities in the size or consistency of lymph nodes. A wide range of etiologies contributes to the difficulty in diagnosing LAP, from mild self-limited viral infections to grave autoimmune diseases and malignancies. Detailed history-taking and a thorough physical examination are essential. Some physicians in developing countries may consider therapeutic testing. Certain groups may require additional evaluations and special treatment. When treating LAP, the etiology is targeted, but corticosteroids should not be administered before a complete diagnosis has been established due to their ability to mask the histological diagnosis of lymphoma and malignancy. This review aims to provide more straightforward and affordable methods available in almost all healthcare settings, especially those with limited resources.

Quantitative Multiparametric Ultrasound (mpUS) in the Assessment of Inconclusive Cervical Lymph Nodes

Background: Enlarged cervical lymph nodes (CLN) are preferably examined by ultrasound (US) by using criteria such as size and echogenicity to assess benign and suspicious CLN, which should be histologically evaluated. This study aims to assess the differentiation of malign and benign CLN by using multiparametric US applications (mpUS). Methods: 101 patients received a standardized US protocol prior to surgical intervention using B-mode−US, shear-wave elastography (SWE) and contrast-enhanced ultrasound (CEUS). SWE was assessed by 2D real-time SWE conducting a minimum of five measurements, CEUS parameters were assessed with post-processing perfusion software. Histopathological confirmation served as the gold standard. Results: B-mode−US and SWE analysis of 104 CLN (36 benign, 68 malignant) showed a significant difference between benign and malignant lesions, presenting a larger long axis and higher tissue stiffness (both p < 0.001). Moreover, tissue stiffness assessed by SWE was significantly higher in CLN with regular B-mode−US criteria (Solbiati Index > 2 and short-axis < 1 cm, p < 0.001). No perfusion parameter on CEUS showed a significant differentiation between benign and malignant CLN. Discussion: As the only multiparametric parameter, SWE showed higher tissue stiffness in malignant CLN, also in subgroups with regular B-mode criteria. This fast and easy application may be a promising noninvasive tool to US examination to ameliorate the sonographic differentiation of inconclusive CLN.

Imaging in children with ataxia-telangiectasia-The radiologist's approach

Ataxia-telangiectasia (A-T) is a syndromic inborn error of immunity (IEI) characterized by genomic instability, defective reparation of the DNA double-strand breaks, and hypersensitivity to ionizing radiation disturbing cellular homeostasis. The role of imaging diagnostics and the conscious choice of safe and advantageous imaging technique, as well as its correct interpretation, are crucial in the diagnostic process and monitoring of children with A-T. This study aimed at defining the role of a radiologist in the early diagnosis of A-T, as well as in detecting and tracking disease complications associated with infections, inflammation, lymphoproliferation, organ-specific immunopathology, and malignancy. Based on our single-center experience, retrospective analysis of investigations using ionizing radiation-free techniques, ultrasound (US), and Magnetic Resonance Imaging (MRI), was performed on regularly followed-up 11 pediatric A-T patients, 6 girls and 5 boys, aged from 2 to 18 years, with the longest period of observation coming to over 13 years. Our attention was especially drawn to the abnormalities that were observed in the US and MRI examinations of the lungs, abdominal cavity, and lymph nodes. The abdominal US showed no abnormalities in organ dimensions or echostructure in 4 out of 11 children studied, yet in the other 7, during follow-up examinations, hepato- and/or splenomegaly, mesenteric, visceral, and paraaortic lymphadenopathy were observable. In 2 patients, focal changes in the liver and spleen were shown, and in one patient progressive abdominal lymphadenopathy corresponded with the diagnosis of non-Hodgkin lymphoma (NHL). The lung US revealed multiple subpleural consolidations and B line artifacts related to the interstitial-alveolar syndrome in 5 patients, accompanied by pleural effusion in one of them. The MRI investigation of the lung enabled the detection of lymphatic nodal masses in the mediastinum, with concomitant airway lesions characteristic of bronchiectasis and focal parenchymal consolidations in one A-T patient with chronic respiratory failure. This patient also manifested organomegaly and granulomatous liver disease in abdominal MRI examination. Our study shows that the use of modern US capabilities and MRI is safe and efficient, thereby serving as a recommended advantageous imaging diagnostic tool in monitoring children with IEI and DNA instability syndromes.

Two-year history of lymphadenopathy and fever caused by Bartonella henselae in a child

We report the case of a 6-year-old boy that presented with enlarged lymph nodes on his neck. He complained of tiredness and discouragement, which worsened during feverish periods. There were no relevant laboratory test abnormalities and serological tests were not reactive. Bartonella henselae DNA was detected by species-specific nested polymerase chain reaction. After treatment, the patient progressed with no fever or lymphadenopathy. Bartonellosis is a group of infectious diseases caused by bacteria of the genus Bartonella. This case report is a useful reminder to clinicians that long-term fever of unknown origin can be related to B. henselae infection, even if the specific serology is not reactive.

Pediatric Neck Masses: Imaging Guidelines and Recommendations

Neck masses commonly present in children and several potential diagnostic and management pathways exist, though with a paucity of evidence-based recommendations. The purpose of this article is to evaluate the current literature and utilization of various diagnostic imaging modalities , with a review of imaging features and management pearls for pediatric neck masses. A comprehensive understanding and practical imaging workflow will guide optimal patient workup and management.

Management of Infectious Lymphadenitis in Children

Lymphadenopathy is an irregularity in the size and texture of the lymph nodes, which is quite common in childhood. When the enlargement of lymph nodes is caused by inflammatory and infectious processes, it is called lymphadenitis. The main objective of this manuscript is to summarize the common infectious etiologies and presentations of lymphadenitis in children providing a management guide for clinical practice. PubMed was used to search for all of the studies published up to April 2021 using keywords such as "lymphadenitis" and "children". Literature analysis showed that the differential diagnosis for lymphadenitis in pediatrics is broad. Although lymph node enlargement in children is usually benign and self-limited, it is important to exclude malignant etiology. In most cases, history and physical examination allow to identify the correct diagnosis and start a proper treatment with a prompt resolution of the lymphadenopathy. However, particularly in the case of persistent lymphadenitis, determining the cause of lymph node enlargement may be difficult, and the exact etiology may not be identified despite extensive investigations. Further studies should develop and validate an algorithm to assist pediatricians in the diagnosis and timely treatment of lymphadenitis, suggesting situations in which a watchful waiting may be considered a safe approach, those in which empiric antibiotic therapy should be administered, and those requiring a timely diagnostic work-up.

Chronic Lateral Neck Mass in an Adolescent Female

Neck masses are a common finding in the pediatric population, with a broad differential diagnosis resulting in real diagnostic challenges. They are most frequently caused by reactive lymphadenopathy, infectious lymphadenitis, or congenital anomalies of the neck. This case report describes a 16-year-old female presenting to the pediatric emergency department with 5 weeks of right-sided neck mass. Based on her history, physical examination, and prolonged clinical course, the differential diagnosis included infectious, congenital, and neoplastic causes. The patient was ultimately diagnosed with a branchial cleft cyst and referred to a pediatric head and neck surgeon.

Clinical and ultrasound characteristics of pediatric lateral neck masses

Lateral neck masses (LNM) often present a diagnostic challenge in the practice of pediatric plastic surgeon. The aim of this study is to investigate the clinical and ultrasound (US) characteristics of pediatric LNM in order to make mutual comparison between their entities and enable the most accurate preoperative diagnosis. A cross-sectional study was conducted among 250 pediatric patients treated by surgical excision or sclerotherapy in our institution in the period from July 2009 to June 2019. Lymphatic malformation was the most frequent congenital LNM (60.9%), while reactive or granulomatous lymphadenitis was the most frequent acquired LNM (47%). Congenital anomalies were significantly more often localized in the upper half of the sternocleidomastoid (SCM) muscle region, and had more often soft consistency than acquired ones. Congenital LNM had a 32.37 (3.44–304.63) times higher likelihood of incorrect (p = 0.002) and 5.86 (1.35–25.48) times higher likelihood of undetermined (p = 0.018) than correct US findings, respectively. Acquired LNM were significantly more often localized in the region behind the SCM muscle and more often had solid US appearance in comparison to the congenital ones. Association of the clinical and US findings is very important in determining the most accurate preoperative diagnosis without exposing the children to unnecessary utilizing ionizing radiation or anesthesia. Although they are mostly benign, extreme caution is necessary due to malignancies which were found in 16.4% of all our patients.

Pediatric Lymphoid and Histiocytic Lesions in the Head and Neck

Lymphoid and histiocytic lesions of the head and neck in pediatric patients is a fascinating topic as most of these lesions are benign, but that the neoplastic cases are essential to diagnose accurately for appropriate treatment. It is thought that 90% of children will have palpable lymph nodes between the ages of 4 to 8; most, but not all, are non-malignant and some resolve spontaneously without treatment. This paper will look at many of the benign and malignant lesions of both lymphocytic and histiocytic origin that present in the head and neck of children focusing on their diagnostic criteria. There is a very pertinent discussion of nonmalignant lymphoid proliferations, as infections and other reactive conditions dominate the pathology of pediatric lymphohistiocytic head and neck lesions. Discussion of those lymphomas which arise more frequently in the head and neck focuses on those seen in children and young adults such as classic Hodgkin lymphoma and Burkitt lymphoma, as well as new more controversial entities such as pediatric-type follicular lymphoma. Histiocytic lesions, both benign and malignant, are described and may be challenging to diagnose.

Ultrasound evaluation of persistent cervical lymph nodes in young children

AIM

To review the ultrasonographic outcomes of persistent lymph nodes, in the absence of other concerning signs or symptoms, in patients <6 years of age.

MATERIALS AND METHODS

A retrospective analysis was undertaken of 98 patients <6 years old who had neck ultrasound for persistent lymph nodes at a single university hospital over a 3.5 year period between January 2016 and June 2019.

RESULTS

There were no cases of malignant disease or serious systemic illness. Ninety-two of the 98 examinations showed normal or reactive lymph nodes. There were three sonographically indeterminate cases and two non-lymph-node structures: haemangioma and dermoid cyst. One examination reported an abnormal lymph node, which had resolved by the time of review in clinic.

CONCLUSION

Persistently enlarged or abnormal lymph nodes should be investigated; however, a distinction should be made between lymph nodes that have regressed to <1 cm but are still palpable and persistently enlarged or abnormal lymph nodes. The findings of the present study indicate that persistence of non-enlarged lymph nodes is not a predictor for malignancy. It is advised that clear guidelines are used, which state the criteria for further investigation, to promote the best use of imaging.

Lymphadenopathy in children: A streamlined approach for the surgeon - A report from the APSA Cancer Committee

BACKGROUND/PURPOSE

Lymphadenopathy is a common complaint in children. Pediatric surgeons are often called upon to evaluate, treat, and/or biopsy enlarged lymph nodes. With many nonsurgical causes in the differential diagnosis, the surgeon plays the important role of providing reassurance and timely diagnosis while minimizing the pain and morbidity associated with surgical interventions in children. The purpose of this summary paper is to provide a management guide for surgeons working up children with lymphadenopathy.

MATERIALS/METHODS

The English language literature was searched for "lymphadenopathy in children". All manuscript types were considered for review, regardless of medical specialty, with emphasis placed on published guidelines, algorithms, and reviews. After thorough review of these manuscripts and cross-referencing of their bibliographies, the attached algorithm was developed, with emphasis on the role and timing of surgical intervention.

RESULTS

The APSA Cancer Committee developed the attached algorithm to fill a gap in the surgical literature. It outlines lymphadenopathy workup and treatment with emphasis on the role and timing of surgical intervention.

CONCLUSION

This review defines and summarizes the common etiologies and presentations of lymphadenopathy in children, and offers a straightforward algorithm for evaluation of and treatment with an emphasis on malignancy risk and surgical management.

TYPE OF STUDY

Summary paper.

LEVEL OF EVIDENCE

Level V.

Evaluation of a unilateral neck mass in a 16-year-old female: Kikuchi-Fujimoto disease with superimposed bacterial lymphadenitis

The evaluation of pediatric neck masses offers the opportunity for consideration of a diverse range of pathologies, from infectious to neoplastic. A 16-year-old female presented with 2 weeks of worsening swelling and pain of a left-sided neck mass. Findings were consistent with Epstein–Barr virus and cytomegalovirus coinfection, but considering profound lymphadenopathy of the supraclavicular, mammillary, and axillary chains, further investigations were undertaken. Hematopathologic examination demonstrated necrotizing lymphadenitis, consistent with Kikuchi-Fujimoto disease. A diagnosis of Kikuchi-Fujimoto disease alongside chronic bacterial lymphadenitis was made on the basis of her response to clindamycin, and the chronic course of her illness and subsequent persistence of the swelling managed on an outpatient basis. The case study describes the initial diagnostic considerations and management as well as a review of the disease pathology.

Kimura disease: a case report of a rare illness presenting as a common complaint

Background Kimura is an uncommon inflammatory cause of pediatric head and neck masses due to eosinophilic infiltration of unclear etiology. Kimura can present similarly to infectious lymphadenitis, a much more common pediatric complaint. This case explores the role of anchoring bias when faced with an illness that at first appears to fit a common illness script that led to a delayed diagnosis. Case presentation A 7-year-old boy presented with acute onset of pre-auricular lymphadenopathy and fevers initially thought to be most consistent with infectious cervical lymphadenopathy. Despite treatment with broad spectrum antibiotics and multiple evaluations for underlying abscess requiring surgical drainage, the patient did not improve and remained febrile. Eventually, excisional lymph node biopsy was obtained and a pathologic diagnosis of Kimura disease was made. Conclusions This case illustrates an uncommon pediatric diagnosis which presented similarly to infectious cervical lymphadenitis without additional laboratory features consistent with Kimura. We highlight the role of anchoring bias and care fragmentation leading to repeat imaging and delayed biopsy in the eventual diagnosis of a rare illness.

Cutaneous ultrasound and its utility in pediatric dermatology. Part I: Lumps, bumps, and inflammatory conditions

High-frequency ultrasonography represents a promising tool for pediatric dermatologists. It is a non-invasive diagnostic technique that is particularly appealing when working with children. It can be easily performed at the patient's bedside, avoiding diagnostic delays, sedation, or multiple visits. It represents a useful adjunct to clinical examination and can enhance our understanding of cutaneous diseases. Patient cooperation and limited training and experience are the main challenges for cutaneous ultrasonography in pediatric dermatology. This review describes cutaneous ultrasonography and the nuances of its use in the pediatric setting, followed by the ultrasonographic findings of cutaneous lumps, bumps, and inflammatory dermatoses commonly encountered in pediatric patients.

Neck and supraclavicular lymphadenopathy secondary to 9-valent human papillomavirus vaccination

We present two clinical cases of lymphadenopathy after vaccination with the human papillomavirus (HPV) 9-valent vaccine: an asymptomatic 11-year-old boy with inferior cervical and supraclavicular lymphadenopathy, and a 13-year-old girl who presented with lymphadenopathy. In both cases, medical history was unremarkable and there was no recent infection, or other clinical findings. Both adolescents had received the HPV 9-valent vaccine in the previous week. In the first case, blood tests, ultrasonography and biopsy were performed, while in the second, a watchful waiting strategy was adopted. In both cases, the lymphadenopathy resolved spontaneously. The boy received the second dose of the vaccine 6 months later and lymphadenopathy reappeared. The Naranjo scale was applied, classifying the events as definite (in the case of the boy) and probable (girl) adverse drug reactions. The vaccine is safe, but recognising this minor adverse event is important to prevent unnecessary investigation and reduce patient and parental anxiety.