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Case presentation

Case presentation . Karen Estrella H. PGY-1. 5y 2m girl. CC: mass in axilla. 2 dys ago 1st episode Tactile fever Tylenol 1.5tsp po x1 Given 8 hrs ago + insect bites + contact with cats no recent travelling No other complains. Mass: Axilla “not warm” “small” Painful

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Case presentation

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  1. Case presentation Karen Estrella H. PGY-1

  2. 5y 2m girl CC: mass in axilla

  3. 2 dys ago 1st episode Tactile fever Tylenol 1.5tsp po x1 Given 8 hrs ago + insect bites + contact with cats no recent travelling No other complains Mass: Axilla “not warm” “small” Painful initially 7/10, now 4/10 More w/ movement HPI

  4. ROS: none • PMHx: • Born in the US, normal anthropometric values, no neonatal complications • No hospitalizations • No surgeries • NKA, NKDA • Vaccines: UTD, PPD (-) 05/06/09 • Diet: family diet • Primary care giver: mother

  5. PE: • VS: • T: 100 P: 110 RR:20 BP: 84/56 • WT: 15.7 kg Ht: 107cm • Gral: Alert, active, in NAD • Skin: scars from mosquito bites, small papular lesion on left palm • HEENT: no nasal or ear discharge, mouth: no lesions, ears: TM wnl • Neck: no adenopathies • Thorax: Heart: RRR no murmurs, Lungs: + clear BL breath sounds • Abdomen: BS+, soft, NT, ND, no masses • Inguinal area: no adenopathies

  6. Extremities: • Left axillary area: • soft, oval mass (1.5cm-2cm), tender to palpation, area of swelling 3cm, not erythematous, no signs of discharge or opening • Tolerable pain to active and passive movements • More with aduction • Other extremities: wnl • Neuro: wnl

  7. Lab • CBC: N: 65.9 L: 26.4 M: 7.1 Ë: 0.2 B: 0.4 11.4 6.8 222 32.9 • Cx………: pending • Titers……: (IgM, IgG) Pending

  8. 1 week later • After initial tx • B. henselae titers: negative • Blood cx: negative • Mom says the mass persists with the same characteristics • PE: vitals: stable • Left axillary mass: unchanged

  9. Lymphadenopathy in children

  10. Lymphadenopathy • Lymph nodes that area abnormal in size, number or consistency. • Types: • Localized • Generalized: 2 or > nodal groups are involved or localized to a single area • Pt age: • (+) in 44% of healthy children under 5yo • (+) in 64% of sick visits

  11. Size: • Axillary and cervical: 1 cm • Inguinal: 1.5cm • Epitrochlear: 0.5cm • Quality: • Reactive: soft, easily compressible, mobile • Infection: tender (lymphadenitis) • Erythema, warmth, induration or fluctuant • Malignancy: fixed, firm

  12. Association • Hx: • Symptoms: • Constitutional: • Fever, night sweats, weight loss, pruritus, arthralgia, fatigue • Local: • Infection nearby organs • Exposure • Animals • Unpasteurized milk • Uncooked meat • Medications: • carbamazepine, cephalosporins, penicillins, phenytoin, sulfonamides • Time

  13. Axillary lymphadenopathy

  14. Differential diagnosis • Cat-scratch disease • Brucellosis • M tuberculosis • Atypical mycobacterias • Reactions to immunizations • Lymphoma • Juvenile rheumathoid arthritis

  15. Cat-scratch fever

  16. MCC of chronic lymphadenopathy in children • Bartonella henselae (G- baccilli) • 90% have + hx for cat exposure (kittens) • > in children < 10 yrs old • Contact: bite, scratch or salive into open wound • Rate of transmission from single contact: unknown • Transmission by cat fleas: minor risk • Incubation period: 7-12 days

  17. Types: UNCOMPLICATED: • Nontender brownish-red papule in site of inoculation, followed by regional adenopathy that develops 1 to 2 weeks later. • Regional nodes continue to enlarge for 2 to 3 weeks, then gradyally recover over the next 1 to 2 months. • Nodes may be small and asymptomatic or become massively enlarged and last several months. • axillary (45%), cervical/submandibular (26%), and groin (18%). • May suppurate late in the course (30%) • Fever 50%, unfrequent: malaise, anorexia, HA

  18. COMPLICATED: • Hepatitis • Parinaud oculoglandular syndrome (POGS): 4% to 6% • Conjunctival nodule, conjunctivitis, and ipsilateral preauricular adenopathy. • Encephalopathy: 0.3% to 2% • CN, peripheral nerve dysfunction cerebellar ataxia, seizures • days to months after the onset of adenopathy • recover completely, usually within 3 months.

  19. Dx • Serologic testing (gold standard) • IgM > 1:16 • IgG: > 1:64 • Humoral response precedes or occurs as the same time as onset of symptoms • IgG levels rise during the 1st 2 months and then gradually decline. • IFA: • Sensitivity: 88-100% • Specificity: 92-98% • EIA: • Sensitivity: 85% • Specificity: 98-99% • Other: • PCR (endocarditis) • Cx: from lymph node takes 6 wks, blood culture: not recommended for lymphadenopathy

  20. Treatment • 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/dDays 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

  21. Brucellosis (G- coccobacilli) • Unpasteurized milk • Sources: • importation of disease (from infected food products or international travel) • cross-border spread from Mexico into neighboring states (mostly affecting Hispanics) Texas • Symptoms: weakness, excessive sweating, lethargy, anorexia, weight loss, arthralgia, myalgia, abdominal pain, and headache. • “undulant fever"

  22. Mycobacterias • Fluctuant lymph nodes develop in weeks to months later • Usually signs of inflamation are absent • ATYPICAL (M. avium, M. scrofolaceum): from contact w/ water or soil rather than p-p as in Tb • Can form cutaneous sinus tracts, and spontaneous rupture • M. tuberculosis: PPD is weakly (+), CXR wnl, and systemic s/s are absent

  23. Lymphoma • > over 10 yrs old • 2/3 of children with ALL and 1/3 of AML • Increasing size, firm, not mobile, irregular surface • Constitutional symptoms (1/3 Hodgkin, 10% non-hodgkin) • Lack of regression in size after 4-6 weeks • Excisional biopsy

  24. Juvenile Rheumatoid Arthritis • Criteria: • onset before age 16 years • arthritis involving one or more joints, or: • presence of at least two of the following findings: • limitation in ROM • tenderness or pain with joint movement • increased fever • disease persisting 6 weeks or longer • clinical features of : polyarthritis (5 or > ), oligoarthritis(< 5), systemic: characteristic arthritis that develops with fever • Lymphadenopathy

  25. Questions

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

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

  28. Of the following, the MOST likely pathogen causing this boy's symptoms is: • Haemophylus influenzae • Pasteurella multiocida • Staphylococcus aureus • Francisella tularensis • Bartonella henselae • 5

  29. You are evaluating a 12yo girl who has a 1 mo Hx of daily fevers ( Tmax: 104), cervical adenopathy, severe malaise, headache 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 learned to milk the cows, feed the pigs and ride horses. She also sampled the local cuisine. PE: febrile, tired-appearing. Diffuse 1x1 cm nontender cervical adenopathy, splenomegaly and tenderness to palpation of her lower back. CBC: WBC: 4.9 x109/L with PMN: 31%, L: 48%, M:6%, Bans: 16%. ESR 70 Of the following, the MOST likely Dx is? • Brucellosis • Cat-scratch disease • EBV mononucleosis • Leptospirosis 1

  30. 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 growing for the past 6 wks. The swelling has not improved after 2 wks of antibiotics. His PE reveals normal findings, with the exception of a 3x2 cm, hard, nonmobile lymph node in the left supraclavicular area. Which of the following is MOST likely to confirm a Dx in this patient? • Blood culture • CXR • Excisional biopsy of the node • FNA of the node • PPD 3

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