Pleural effusion, lymphnodes and hepatosplenomegaly

Dr Ira Shah

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Pleural effusion, lymphnodes and hepatosplenomegaly

Dr Ira Shah.

Medical Sciences Department, Pediatric Oncall, Mumbai.

ADDRESS FOR CORRESPONDENCE
Medical Sciences Department, Pediatric Oncall, Mumbai

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Clinical Problem
A 10 year old boy born of non-consanguineous marriage presented with left sided progressive swelling over neck since 10 days, fever and cough since 3 days and breathless since 2 days. The child was treated with antibiotics for the same but there was no improvement. Father was diagnosed to have Pulmonary TB 3 years back (was sputum for AFB-negative) and received antituberculous therapy (ATT) for 6 months. On examination, the child was febrile with heart rate of 150/minute and respiratory rate of 60/min without intercostal retraction. Blood pressure was 120/80 mm of Hg. Left cervical adenopathy was present 5 x 6 cm which was rubbery and tender. Also bilateral axillary and inguinal nodes were palpable. On systemic examination, there was a bulge on right side of chest with decreased chest movements on right side. Air entry was decreased on right side and dull note was present on palpation with shift of apex beat to the left side outside the mid-clavicular line. Air entry was decreased on right side. He had tender hepatosplenomegaly. Other systemic examination was normal.

What is the diagnosis?

Discussion
Expert’s opinion:- Dr Ira Shah

This child has a right sided pleural effusion, fever, generalized lymphadenopathy with a left cervical gland which is very large and rubbery and hepatosplenomegaly. Hence one would consider a diagnosis of
• Lymphoma / Systemic malignancy
• Tuberculosis
• Bacterial infection and empyema

Though, there is a history of TB in the father, he did not have sputum positive Koch’s, hence he is unlikely to be TB contact. Also tuberculous effusion is usually seen in patients with a better immunity. It does not lead to disseminated TB. Hence it would be unlikely that the child should have fever, hepatosplenomegaly and such large adenopathy due to tuberculosis.
In a child with bacterial pleural effusion, empyema can lead to fever and pleural effusion. Also, hepatosplenomegaly can be seen with septicemia. However large cervical adenopathy is unlikely unless it is an abscess. Also this child was treated with antibiotics prior to presentation and that should have at least partially controlled his symptoms.
Thus, the most likely diagnosis in this child would be lymphoma. Lymphoma presents usually with cervical adenopathy which is rubbery to feel. Lymphoma is a very rapid progressive tumor and can lead to invasion of other systems very soon. Hence, pleural effusion, hepatosplenomegaly, bone marrow involvement may be seen in a matter of days in which case the child would be diagnosed as leukemia. LYMPHOMA is an oncological emergency and needs to be diagnosed soon and treated urgently. This child’s hemogram showed WBC count of 1,14,000/cumm with platelet count of 81,000/cumm and 100% blasts on peripheral smear. X-Ray Chest showed right pleural effusion with superior mediastinal adenopathy. Pleural fluid was hemorrhagic and LDH and uric acid levels were high. This child was treated with steroids as emergency therapy and subsequently started on chemotherapy.

Compliance with ethical standards

Funding: None

Conflict of Interest: None

Cite this article as:
Shah I. Pleural effusion, lymphnodes and hepatosplenomegaly. Pediatr Oncall J. 2007;4: 18.