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Lymphadenopathy in African Children 245

Figure 37.5: Chest x-ray (left) and CT scan (right) showing mediastinal node
effect on airway.

Localised Lymphadenopathy
Cervical Lymphadenopathy Figure 37.6: Cervical lymphadenopathy as a result of Hodgkin’s lymphoma in a
Cervical lymphadenopathy is a common clinical problem in children; 10-year-old boy.
two-thirds of affected patients are older than 5 years of age. Cervical
lymphadenopathy is extremely common in developing populations and
could therefore be expected to include a higher percentage of patients
with acute infection, tuberculosis, neoplasia, and related diseases.
Lymphadenopathy in the posterior triangle of the neck is viewed
with suspicion because lymphoma often presents there (Figure 37.6).
In addition, the presence of an enlarged post auricular node in
children older than 2 years of age is likely to be clinically significant.
Lymphadenopathy in the supraclavicular region is highly significant, as
up to 60% are caused by malignant tumours.
The clinicopathological spectrum of lymphadenopathy is not always
predictable on clinical grounds, and cervical lymph nodes are often
asymptomatic. The differential diagnosis largely encompasses reactive
hyperplasia, specific infective agents, or malignancy. The obvious
therapeutic and prognostic implications necessitate an accurate and
prompt diagnosis. Nonresponse to empiric antibiotic therapy is a major
criterion for further investigation. Surgical intervention provides material
to establish an early diagnosis and is thus a vital part of management.
Although chronic lymphadenopathy in children of developing
countries has a high incidence of infective causes, including Figure 37.7: Rapidly enlarging lymph nodes in a 4-year-old boy with lymphoma.
mycobacteria; it has an approximate 11% risk of malignancy. More
than half the cervical lymph nodes examined in children in a developing
Rapidly enlarging lymphadenopathy suggests malignant disease
country displayed very significant and clinically important pathology,
(Figure 37.7). The highest incidence of malignancy occurs in the
thereby justifying active management of all paediatric patients with
supraclavicular lymph nodes.
persistent cervical lymphadenopathy.
The largest safely accessible node is selected for biopsy. Correct Axillary and Inguinal Nodes
handling of a lymph node biopsy is essential. Nodes are divided in half, Enlarged lymph nodes of the axilla and groin are unusual presenting
with half going fresh to histopathology for imprints and histology. The sites for lymphomas, which are the most common forms of malignancy
remaining half is further subdivided in two, with one section being sent seen involving lymph nodes. Hodgkin’s lymphoma may present with
for tissue culture and the remaining section for TB culture. enlarged axillary nodes.
The causes of lymphadenopathy may vary from upper respiratory The presence of lymphadenopathy in atypical anatomic regions,
viral infections (e.g., adenovirus, rhinovirus, enterovirus) to the more persistence despite appropriate treatment, absence of previous pyogenic
common childhood diseases (e.g., measles, mumps, rubella, herpes) infection, geographical prevalence, history of cat scratch, and a positive TB
and other specific viral infections (e.g., cytomegalovirus, EBV, and history are all significant clues for suspecting the diagnosis of lymphoma.
HIV/AIDS (acquired immune deficiency syndrome) within endemic Early tissue sampling may be indicated if the postauricular,
regions). A number of noninfective causes should also be considered in epitrochlear, mediastinal, and abdominal lymph nodes are involved in
addition to the viral diseases, such as sarcoidosis, Kawasaki disease, and the presence of generalised symptoms of unexplained fever and weight
cat scratch disease in addition to the mycobacterial group of organisms. loss. The presence of large mediastinal and hilar nodes may lead to
Axillary lymphadenopathy is mostly associated with malignancy (e.g., anaesthetic hazards and must be evaluated prior to a surgical procedure
Hodgkin’s) and cervical lymphadenopathy mostly associated with TB (e.g., biopsy) being undertaken.
(although a significant number are malignant). Special Investigations
Lymphadenopathy is not an uncommon feature of viral and
Depending on the clinical presentation, the initial visit may require little
rickettsial infections and may be a part of infectious diseases such as
or no special investigations if an empiric trial of antibiotics for proven
rubella, infectious mononucleosis, and certain tropical diseases (e.g.,
or suspected infection is anticipated. In a subsequent visit, basic special
dengue fever). In infectious mononucleosis, the lymphadenopathy is
investigations, such as a white cell count, Mantoux test, and a chest
mostly cervical and epitrochlear.
x-ray become the initial screening tools. Further investigation depends