CLINICO-PATHOLOGICAL PROFILE OF PEDIATRIC SIGNIFICANT CERVICAL LYMPHADENOPATHY
Doddamani Mahesh*, Akki.A.S, Hipparagi S.B **
BLDEA's Shri B.M.Patil Medical College, Hospital & Research Centre, BIJAPUR. *, BLDEA's Shri B.M.Patil Medical College, Hospital & Research Centre, BIJAPUR. **
Objective
To study the clinico-pathological profile of pediatric significant cervical lymphadenopathy and to arrive at an aetiological diagnosis.
Materials and Methods
Prospective study in a tertiary care hospital setting. Thirty two consecutive children reporting to the Department of Pediatrics from 1 November 2005 to 31 August 2006 aged 1 month to 12 years were studied. Fine needle aspiration cytology, Mantoux test and hematological parameters were performed in all the cases. Additional investigations like culture, serological tests and roentgenogram were done wherever required.
Thirty two consecutive children with significant cervical lymphadenopathy attending Department of Pediatrics at B.L.D.E.A's Shri B.M. Patil Medical College, hospital & research center, Bijapur with age ranging from 1 month to 12 years formed the study material. Study conducted from 1st Nov 2005 to 31st Aug 2006. Significant lymphadenopathy for the purpose of study constituted (i) lymphnodes in the cervical region more than 1 cm (ii) lymphnodes which are hard & rubbery in consistency on palpation (iii) matted/fixed lymphnodes (iv) lymphnodes with discharging sinus.

A detailed history with thorough general physical examination and systemic examination was carried out in all the cases. Mandatory investigations carried out included (i) Complete Hemogram (ii) Mantoux test and (iii) FNAC. Additional investigations like Culture, Serological tests and Roentgenogram were done wherever required.
Results
Among 32 cases studied, common age group presenting with significant lymphadenopathy was school-going children with 21 (65.62%). There was male preponderance with male: female ratio being 1.67:1 (20:12). The aetiology was confirmed in 21 (65.62%) cases and could not be ascertained in 10 (31.25%) cases even after detailed hematological, microbiological, radiological and serological investigations. Cytological examination revealed reactive lymphadenitis in 25 (78.12%) cases, tubercular lymphadenitis in 4 (12.5%) cases and suppurative lymphadenitis in 2 (6.25%) cases. Also, one case with persistent lymphadenopathy yielded inadequate aspirate. The commonest aetiology diagnosed after detailed investigation was streptococcal infections and tuberculosis in 4 (12.5%) cases each followed by Staphylococcal infections 3(9.35). In addition, there was 1(3.12%) case each of HIV and Citrobacter.

Of the 32 cases in the present study, predominant age group was 6-12 years in 21 (65.5%) followed by 1-5 years in 9 (28.12%) cases. There was a male preponderance accounting for 21 (65.5%) cases with M:F ratio being 1.9:1. The common symptom noted was swelling in neck region in 23 (71.8%) cases followed by fever in 18 (56.25%) cases, cough in 15 (46.6%) cases, sore throat in 14 (43.75%) and ear discharge in 2 (6.25%) cases. Among 32 cases, anterior and posterior group of lymph nodes were enlarged in 19 (59.3%) cases, only anterior group in 9 (28.12%) cases and only posterior group in 4 (12.5%) cases. Majority of the cases had bilateral cervical lymphadenopathy in 19 (59.3%) cases. Generalized lymphadenopathy was observed in 13 (40.6%) cases. History of contact with adult tuberculosis was seen in 1 (3.12%) case and past history of tuberculosis in 3 (9.37%) cases. Of the 32 cases, 9 (28.1%) were fully immunized, 18 (56.2%) cases were partially immunized and 5 (15.6%) were unimmunised. BCG scar was observed in 25 (78.1%) cases and in remaining 7 (21.8%) cases scar was not seen of which 2 (6.2%) cases were fully immunized. Undernourishment was seen in 19 (59.3%) cases and 3 (9.3%) cases were marasmic.
Conclusion
Reactive lymphadenitis due to underlying infection caused by streptococcal and staphylococcal infections were the commonest treatable entity of significant pediatric cervical lymphadenopathy. Further studies and longer follow-up involving detection of antigen and antibodies against lesser known viruses, parasites and rarer causes of lymphadenopathy may decrease the fraction of undiagnosed reactive conditions.
Introduction
Cervical lymph node enlargement is a common clinical finding in pediatric practice. Enlargement of lymph node may result from the proliferation of lymphocytes intrinsic to the lymph node either duo to infection or due to lymphoproliferative disorder or from the migration and infiltration of nodal tissue by either extrinsic inflammatory cells or metastatic malignant cells. The etiological profile varies from country to country and region to region. In developing country like India, acute respiratory infections, suppurative skin infections and tuberculosis are the major causes for regional lymphadenopathy. Any failure to decrease in size of lymph node within 10-14 days of treatment, a need for further evaluation is indicated. Hence, the present study was undertaken to evaluate these cases and to arrive at an etiological diagnosis.
Possible Etiology by Clinical Diagnosis

Clinical Diagnosis

  no. (%)

Tonsillopharyngitis

  14 (43.75%)

Tuberculosis

  4 (12.5%)

Otitis media

  2 (6.25%)

HIV

  1 (3.12%)

 Inadequate

  1 (3.12%)

Undiagnosed

  10 (31.25%)

Cytological Diagnosis

 Cytological Diagnosis

  no. (%)

  Reactive lymphadenitis

  25 (78.12%)

  Tubercular lymphadenitis

  4 (12.5%)

  Suppurative lymphadenitis

  2 (6.25%)

  Inadequate aspirate

  1 (3.13%)

Table showing Clinically Diagnosed Cases and Confirmed Cases

Clinically Diagnosed cases. no.(%) Confirmed cases no. (%) Total no.(%)

Tonsillopharyngitis 6 (18.75%)

Streptococcus spp 4 (12.5%)

12 (37.5%)

S. aureus 2(6.25%)

Tuberculosis 2 (6.25%) By FNAC 4 (12.5%) 6 (18.75%)

Otitis media -------

Citrobacter spp. 1 (3.12%)

2 (6.25%)

S. aureus 1(3.12%)

HIV --------

By Tri-dot 1 (3.12%)

1 (3.12%)

Inadequate 1 (3.12%)

----

1 (3.12%)

Undiagnosed 10 (31.25%)

-----

10 (31.25%)

Discussion
In this study, an attempt was made to study the etiology of children with cervical lymphadenopathy after correlating with history, clinical findings and relevant laboratory diagnosis. In our study, majority of the children presenting in age group of 6-12 years, probably due to increase in exposure to surrounding environment. However Reddy. MP et al noted majority in 4-8 years group. But Knight et al emphasised in one of the largest studies relating age to lymphadenopathy that age is not important in predicting the incidence of significant lymphadenopathy. In the present study, there is male preponderance, but there is no such predilection of sex in study by Mishra SD et al.

In the present study, predominant symptom was swelling in neck followed by fever and cough which is correlated with observation of Reddy. MP et al. Knight et al and Reddy et al observed in their study of pediatric cervical lymphadenopathy, the predominant site being upper anterior cervical lymph nodes. However in our study, the predominant sites included both anterior and posterior lymph nodes. In the present study children with history of contact with adults, tuberculosis was present in 3.12% cases. However Reddy. MP et al noted the same in 90.90%. Knight et al and Reddy. MP et al noted firm lymphnodes in 96% and 94% cases respectively and our finding (81.25%) is corroborated with the above workers. BCG scar was noted in 78.12% cases in present study which is well correlated with Reddy. MP et al who also noted it in 78%. This may be attributable to awareness about the immunization.

In the present study, the commonest cytopathological finding was reactive lymphadenitis in 78.12% followed by granulomatous and suppurative lymphadenitis in 12.5% and 6.25% respectively. Lake et al and Reddy. MP et al also noted the commonest cytopathological finding as reactive lymphadenitis followed by granulomatous lymphadenitis. Tubercular lymphadenitis which was observed in the present study correlated positively with increasing risk factors like unimmunised status, positive Mantoux test, positive history of contact and undernourishment. Other bacterial pathogens like Staphylococci, Streptococci and Citrobacter which are isolated from tonsillopharyngitis and otitis media are involved in causing cervical lymphadenopathy. This may be attributed to poor hygienic conditions, overcrowding and low socio-economic status. Finding of one case of HIV infection in the present study correlated with history of exposure in mother and recent HIV scourge.

In the present study, etiology could not be established in 11 (34.37%) of the cases inspite of various investigations and this finding was well correlated with Reddy. MP et al who was unable to diagnose in 44% of the cases. Hence, further studies and longer follow up involving detection of antigen and antibody against various viruses, parasites and investigations for rare causes of lymphadenopathy may decrease the number of undiagnosed cases.
References :
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  2. Reddy MP, Moorchung N, Chaudhary A. Clinico-pathological profile of pediatric lymphadenopathy. Indian J Pediatr 2002; 69(12): 1047-1051.
  3. Morland B. Lymphadenopathy. Arch Dis Child 1995;73:476- 479.
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