Case presentation

Case presentationCase presentationKaren Estrella H.Karen Estrella H.

PGY-1PGY-1

5y 2m girl5y 2m girlCC: mass in axillaCC: mass in axilla

HPIHPI

2 dys ago2 dys ago 1st episode1st episode Tactile feverTactile fever

Tylenol 1.5tsp po x1Tylenol 1.5tsp po x1 Given 8 hrs agoGiven 8 hrs ago

+ insect bites+ insect bites + contact with cats+ contact with cats no recent travellingno recent travelling No other complainsNo other complains

Mass:Mass: AxillaAxilla ““not warm”not warm” ““small”small” PainfulPainful

initially 7/10, now 4/10initially 7/10, now 4/10 More w/ movementMore w/ movement

ROS: noneROS: none PMHx: PMHx:

Born in the US, normal anthropometric values, Born in the US, normal anthropometric values, no neonatal complicationsno neonatal complications

No hospitalizationsNo hospitalizations No surgeriesNo surgeries NKA, NKDANKA, NKDA Vaccines: UTD, PPD (-) 05/06/09Vaccines: UTD, PPD (-) 05/06/09 Diet: family dietDiet: family diet Primary care giver: motherPrimary care giver: mother

PE:PE: VS:VS:

T: 100 P: 110 T: 100 P: 110 RR:20 BP: 84/56 RR:20 BP: 84/56 WT: 15.7 kgWT: 15.7 kg Ht: 107cmHt: 107cm

Gral:Gral: Alert, active, in NAD Alert, active, in NAD Skin:Skin: scars from mosquito bites, small papular lesion scars from mosquito bites, small papular lesion

on left palmon left palm HEENT:HEENT: no nasal or ear discharge, mouth: no lesions, no nasal or ear discharge, mouth: no lesions,

ears: TM wnlears: TM wnl Neck:Neck: no adenopathies no adenopathies Thorax:Thorax: Heart: RRR no murmurs, Lungs: + clear BL Heart: RRR no murmurs, Lungs: + clear BL

breath soundsbreath sounds Abdomen:Abdomen: BS+, soft, NT, ND, no masses BS+, soft, NT, ND, no masses Inguinal area:Inguinal area: no adenopathies no adenopathies

Extremities:Extremities: Left axillary area: Left axillary area:

soft, oval mass (1.5cm-2cm), tender to palpation, soft, oval mass (1.5cm-2cm), tender to palpation, area of swelling 3cm, not erythematous, no signs area of swelling 3cm, not erythematous, no signs of discharge or openingof discharge or opening

Tolerable pain to active and passive movements Tolerable pain to active and passive movements More with aductionMore with aduction

Other extremities: wnlOther extremities: wnl

Neuro: wnlNeuro: wnl

LabLab

CBC:CBC:

6.8

11.4

32.9

222

N: 65.9

L: 26.4

M: 7.1

Ë: 0.2

B: 0.4

Cx………: pending

Titers……: (IgM, IgG) Pending

1 week later1 week later

After initial txAfter initial tx B. henselae titers: negativeB. henselae titers: negative Blood cx: negativeBlood cx: negative

Mom says the mass persists with the Mom says the mass persists with the same characteristicssame characteristics

PE: vitals: stablePE: vitals: stable Left axillary mass: unchangedLeft axillary mass: unchanged

Lymphadenopathy in Lymphadenopathy in childrenchildren

LymphadenopathyLymphadenopathy

Lymph nodes that area abnormal in size, Lymph nodes that area abnormal in size, number or consistency.number or consistency.

Types:Types: Localized Localized Generalized: 2 or > nodal groups are involved or Generalized: 2 or > nodal groups are involved or

localized to a single arealocalized to a single area

Pt age:Pt age: (+) in 44% of healthy children under 5yo (+) in 44% of healthy children under 5yo (+) in 64% of sick visits(+) in 64% of sick visits

Size:Size: Axillary and cervical: 1 cmAxillary and cervical: 1 cm Inguinal: 1.5cmInguinal: 1.5cm Epitrochlear: 0.5cmEpitrochlear: 0.5cm

Quality:Quality: Reactive: soft, easily compressible, mobileReactive: soft, easily compressible, mobile Infection: tender (Infection: tender (lymphadenitis)lymphadenitis)

Erythema, warmth, induration or fluctuantErythema, warmth, induration or fluctuant Malignancy: fixed, firmMalignancy: fixed, firm

AssociationAssociation

Hx: Hx: Symptoms:Symptoms:

Constitutional:Constitutional: Fever, night sweats, weight loss, pruritus, arthralgia, fatigueFever, night sweats, weight loss, pruritus, arthralgia, fatigue

Local:Local: Infection nearby organsInfection nearby organs

ExposureExposure AnimalsAnimals Unpasteurized milkUnpasteurized milk Uncooked meatUncooked meat

Medications: Medications: carbamazepine, cephalosporins, penicillins, phenytoin, carbamazepine, cephalosporins, penicillins, phenytoin,

sulfonamidessulfonamides TimeTime

Axillary lymphadenopathyAxillary lymphadenopathy

Differential diagnosisDifferential diagnosis

Cat-scratch diseaseCat-scratch disease BrucellosisBrucellosis M tuberculosisM tuberculosis Atypical mycobacteriasAtypical mycobacterias Reactions to immunizationsReactions to immunizations LymphomaLymphoma Juvenile rheumathoid arthritisJuvenile rheumathoid arthritis

Cat-scratch feverCat-scratch fever

MCC of chronic lymphadenopathy in childrenMCC of chronic lymphadenopathy in children

Bartonella henselae (G- baccilli)Bartonella henselae (G- baccilli)

90% have + hx for cat exposure (kittens)90% have + hx for cat exposure (kittens) > in children < 10 yrs old> in children < 10 yrs old

Contact: bite, scratch or salive into open woundContact: bite, scratch or salive into open wound Rate of transmission from single contact: unknownRate of transmission from single contact: unknown Transmission by cat fleas: minor riskTransmission by cat fleas: minor risk

Incubation period: 7-12 daysIncubation period: 7-12 days

Types:Types:

UNCOMPLICATED:UNCOMPLICATED: Nontender brownish-red papule in site of inoculation, Nontender brownish-red papule in site of inoculation,

followed by regional adenopathy that develops 1 to 2 followed by regional adenopathy that develops 1 to 2 weeks later. weeks later.

Regional nodes continue to enlarge for 2 to 3 weeks, Regional nodes continue to enlarge for 2 to 3 weeks, then gradyally recover over the next 1 to 2 months.then gradyally recover over the next 1 to 2 months.

Nodes may be small and asymptomatic or become Nodes may be small and asymptomatic or become massively enlarged and last several months. massively enlarged and last several months. axillary (45%), cervical/submandibular (26%), and groin axillary (45%), cervical/submandibular (26%), and groin

(18%).(18%). May suppurate late in the course (30%)May suppurate late in the course (30%)

Fever 50%, unfrequent: malaise, anorexia, HA Fever 50%, unfrequent: malaise, anorexia, HA

COMPLICATED:COMPLICATED: HepatitisHepatitis Parinaud oculoglandular syndrome (POGS): 4% to 6% Parinaud oculoglandular syndrome (POGS): 4% to 6%

Conjunctival nodule, conjunctivitis, and ipsilateral Conjunctival nodule, conjunctivitis, and ipsilateral preauricular adenopathy.preauricular adenopathy.

Encephalopathy: 0.3% to 2%Encephalopathy: 0.3% to 2% CN, peripheral nerve dysfunction cerebellar ataxia, CN, peripheral nerve dysfunction cerebellar ataxia,

seizuresseizures days to months after the onset of adenopathydays to months after the onset of adenopathy

recover completely, usually within 3 months.recover completely, usually within 3 months.

DxDx Serologic testing (gold standard)Serologic testing (gold standard)

IgM > 1:16IgM > 1:16 IgG: > 1:64IgG: > 1:64 Humoral response precedes or occurs as the same time as onset of Humoral response precedes or occurs as the same time as onset of

symptomssymptoms IgG levels rise during the 1st 2 months and then gradually decline.IgG levels rise during the 1st 2 months and then gradually decline.

IFA: IFA: Sensitivity: 88-100%Sensitivity: 88-100% Specificity: 92-98%Specificity: 92-98%

EIA:EIA: Sensitivity: 85%Sensitivity: 85% Specificity: 98-99%Specificity: 98-99%

Other: Other: PCR (endocarditis)PCR (endocarditis) Cx: from lymph node takes 6 wks, blood culture: not recommended for Cx: from lymph node takes 6 wks, blood culture: not recommended for

lymphadenopathy lymphadenopathy

TreatmentTreatment

Self-limited Supportive care Antibiotics:

Antibiotic therapy little or no improvement some improvement in regression of lymph node size after the

use of azythromycin vs placebo (1st mo) Day 1: 10 mg/kg PO once; not to exceed 500 mg/d

Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d USE IN: immunocompromised Pts

Macrolides, rifampin,doxycycline,ciprofloxacin, or gentamicin.

Suppurative lymph nodes: needle aspiration For complicated: steroids(?) can be added to antibiotics

Brucellosis Brucellosis (G- coccobacilli)(G- coccobacilli)

Unpasteurized milkUnpasteurized milk Sources: Sources:

importation of disease (from infected food products or importation of disease (from infected food products or international travel) international travel)

cross-border spread from Mexico into neighboring cross-border spread from Mexico into neighboring states (mostly affecting Hispanics) Texasstates (mostly affecting Hispanics) Texas

Symptoms: weakness, excessive sweating, Symptoms: weakness, excessive sweating, lethargy, anorexia, weight loss, arthralgia, lethargy, anorexia, weight loss, arthralgia, myalgia, abdominal pain, and headache.myalgia, abdominal pain, and headache.

““undulant fever"undulant fever"

MycobacteriasMycobacterias

Fluctuant lymph nodes develop in weeks to Fluctuant lymph nodes develop in weeks to months latermonths later

Usually signs of inflamation are absentUsually signs of inflamation are absent ATYPICAL (M. avium, M. scrofolaceum): from ATYPICAL (M. avium, M. scrofolaceum): from

contact w/ water or soil rather than p-p as in Tbcontact w/ water or soil rather than p-p as in Tb Can form cutaneous sinus tracts, and spontaneous Can form cutaneous sinus tracts, and spontaneous

rupturerupture

M. tuberculosis: PPD is weakly (+), CXR wnl, M. tuberculosis: PPD is weakly (+), CXR wnl, and systemic s/s are absentand systemic s/s are absent

LymphomaLymphoma

> over 10 yrs old> over 10 yrs old 2/3 of children with ALL and 1/3 of AML2/3 of children with ALL and 1/3 of AML Increasing size, firm, not mobile, irregular Increasing size, firm, not mobile, irregular

surfacesurface Constitutional symptoms (1/3 Hodgkin, Constitutional symptoms (1/3 Hodgkin,

10% non-hodgkin)10% non-hodgkin) Lack of regression in size after 4-6 weeksLack of regression in size after 4-6 weeks Excisional biopsyExcisional biopsy

Juvenile Rheumatoid ArthritisJuvenile Rheumatoid Arthritis

Criteria:Criteria: onset before age 16 yearsonset before age 16 years arthritis involving one or more joints, or: arthritis involving one or more joints, or: presence of at least two of the following findings:presence of at least two of the following findings:

limitation in ROMlimitation in ROM tenderness or pain with joint movementtenderness or pain with joint movement increased feverincreased fever disease persisting 6 weeks or longerdisease persisting 6 weeks or longer clinical features of : polyarthritis (5 or > ), oligoarthritis(< 5), clinical features of : polyarthritis (5 or > ), oligoarthritis(< 5),

systemic: characteristic arthritis that develops with feversystemic: characteristic arthritis that develops with fever LymphadenopathyLymphadenopathy

QuestionsQuestions

A worried mother brings her 4-year-old son to A worried mother brings her 4-year-old son to your office because his right eye has been red your office because his right eye has been red for 3 days. She assumed it was pink eye that he for 3 days. She assumed it was pink eye that he contracted at child care, but she now is contracted at child care, but she now is concerned because he has developed swelling concerned because he has developed swelling in front of his right ear, and his eye has become in front of his right ear, and his eye has become redder. redder.

They live in a wooded area They live in a wooded area and got a new kitten 6 weeks and got a new kitten 6 weeks ago, but there is no history of ago, but there is no history of the kitten scratching the child. the kitten scratching the child. Physical examination reveals a Physical examination reveals a well-appearing child who has well-appearing child who has obvious conjunctival injection obvious conjunctival injection of the right eye but no of the right eye but no discharge or pain. You palpate discharge or pain. You palpate a 2x2-cm tender, mobile a 2x2-cm tender, mobile preauricular lymph node and a preauricular lymph node and a 2x3-cm anterior cervical lymph 2x3-cm anterior cervical lymph node on the right. The node on the right. The remainder of the physical remainder of the physical examination findings are examination findings are normal.normal.

Of the following, the MOST likely pathogen Of the following, the MOST likely pathogen causing this boy's symptoms is:causing this boy's symptoms is:

1.1.Haemophylus influenzaeHaemophylus influenzae2.2.Pasteurella multiocidaPasteurella multiocida3.3.Staphylococcus aureusStaphylococcus aureus4.4.Francisella tularensisFrancisella tularensis5.5.Bartonella henselaeBartonella henselae

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You are evaluating a 12yo girl who has a 1 mo Hx of daily fevers You are evaluating a 12yo girl who has a 1 mo Hx of daily fevers ( Tmax: 104), cervical adenopathy, severe malaise, headache and ( Tmax: 104), cervical adenopathy, severe malaise, headache and lower back pain. No sick contacts at home. She has a 5 yo cat and lower back pain. No sick contacts at home. She has a 5 yo cat and 2 birds as pets. 6 mo ago she spent 2 wks at Mexico where she 2 birds as pets. 6 mo ago she spent 2 wks at Mexico where she learned to milk the cows, feed the pigs and ride horses. She also learned to milk the cows, feed the pigs and ride horses. She also sampled the local cuisine. sampled the local cuisine.

PE: febrile, tired-appearing. Diffuse 1x1 cm nontender cervical PE: febrile, tired-appearing. Diffuse 1x1 cm nontender cervical adenopathy, splenomegaly and tenderness to palpation of her adenopathy, splenomegaly and tenderness to palpation of her lower back.lower back.

CBC: WBC: 4.9 x10CBC: WBC: 4.9 x1099/L with PMN: 31%, L: 48%, M:6%, Bans: /L with PMN: 31%, L: 48%, M:6%, Bans: 16%. ESR 7016%. ESR 70

Of the following, the MOST likely Dx is?Of the following, the MOST likely Dx is?

1.1. BrucellosisBrucellosis2.2. Cat-scratch diseaseCat-scratch disease3.3. EBV mononucleosisEBV mononucleosis4.4. LeptospirosisLeptospirosis

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A 14 yo male boy is referred to the hospital for evaluation of a A 14 yo male boy is referred to the hospital for evaluation of a swollen lymph node, which his mother says has been present and swollen lymph node, which his mother says has been present and growing for the past 6 wks. The swelling has not improved after 2 growing for the past 6 wks. The swelling has not improved after 2 wks of antibiotics. His PE reveals normal findings, with the wks of antibiotics. His PE reveals normal findings, with the exception of a 3x2 cm, hard, nonmobile lymph node in the left exception of a 3x2 cm, hard, nonmobile lymph node in the left supraclavicular area. supraclavicular area.

Which of the following is MOST likely to confirm a Dx in this Which of the following is MOST likely to confirm a Dx in this patient?patient?

1.1. Blood cultureBlood culture2.2. CXRCXR3.3. Excisional biopsy of the nodeExcisional biopsy of the node4.4. FNA of the nodeFNA of the node5.5. PPDPPD

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