7 and 8. Lump in neck and lymphadenopathy Flashcards
History taking neck lump/lymphadenopathy
Duration of onset
Any recent change in size, number of neck lumps
Associated symptoms (especially red flag symptoms, discussed below)
Relevant past medical history – smoking status, alcohol intake, previous head and neck cancers, and known radiation exposure (e.g. previous radiotherapy)
How long has the lump been present?
Is it painful?
Has it changed? If so, over what time frame?
Are there symptoms of recent infection of nearby structures (cough, cold, sore throat, earache, toothache, skin problems, head lice, bites)?
Has there been a fever?
Does eating affect the lump?
Is there pain when swallowing?
Is there any effect on voice?
Does the person smoke?
Is there a history of travel?
Is there a past history of cancer?
Are there red flag symptoms of systemic illness? For example:
Night sweats.
Weight loss.
Unexplained bruising or bleeding.
Persistent fatigue.
Breathlessness.
Examination neck lump and lymphadenopathy
Look, feel, move
LOOK:
Location (anterior triangle, posterior triangle or midline)
Size
Shape (oval, round or irregular)
Skin changes (erythema, tethering or ulceration)
Pulsatile (e.g., carotid body tumours)
FEEL
Consistency (hard, soft or rubbery)
Surface eg rough, smooth, irregular
Shape
Warmth (e.g., infection)
Tenderness (e.g., infection)
Size: use a tape measure
Compressible?
Fluctuant?
Pulsatile (high blood flow) or expansile (aneurysmal)? Is there a palpable thrill?
MOVE
● Skin tethering - attempt to pick up a fold of skin over the swelling and compare the
degree of tethering with the other side
● Tethering to deeper structures - attempt to move the swelling in different planes
relative to the surrounding tissues.
● Tethering to muscles and tendons - palpate the swelling whilst asking the patient to
use the relevant muscle.
Movement with swallowing (e.g., thyroid lumps) or sticking their tongue out (e.g., thyroglossal cysts)
Special tests:
Transilluminates with light (e.g., cystic hygroma – usually in young children)
● Auscultation for bruits or bowel sounds
ENT
- ear infections –> reactive lymphadenopathy
- nose –> h&n ca,
- throat - h&n ca,
Thyroid
Cranial nerves
Respiratory
- clubbing - lung ca
Abdo
- hepatosplenomegaly eg EBV, leukemia, lymphoma
- gastric ca
differentials neck lump and lymphadenopathy
Infectious
Reactive lymphadenopathy eg post-URTI
Skin infection such as abscess
Measles, mumps, rubella
Generalised lymphadenopathy (HIV, EBV, HSV, CMV)
Cat scratch disease
Extra-pulmonary tuberculosis
Specific risks (toxoplasmosis, lyme disease, cat scratch)
Immune
Amyloidosis
Sarcoidosis
Kawasaki
Malignant lymphadenopathy
Lymphoma
Leukaemia
Tumours
Head and neck cancer
Sarcoma
Salivary gland tumours/pathology
Metastasis - lung and gastric
Lipoma
Neural tumours
Vascular tumours such as hemangioma
Thyroid
Goitre
Congenital
Thyroglossal cyst
Cystic hygroma
Branchial cyst
Dermoid cyst
Degenerative
Pharyngeal pouch
Vascular
Carotid body tumour
Carotid aneurysm
Trauma
Haematoma
red flags for lump in neck ?
buffer
infectious ddx lump in neck
Reactive lymphadenopathy eg post-URTI
Skin infection such as abscess
Measles, mumps, rubella
Generalised lymphadenopathy (HIV, EBV, HSV, CMV)
Cat scratch disease
Extra-pulmonary tuberculosis
Specific risks (toxoplasmosis, lyme disease, cat scratch)
what is the most common cause of neck swellings?
Reactive lymphadenopathy
what local lesions of infection may you see on the neck
boils
carbuncle
abscess
pustule
boil vs carbuncle
Boil/furuncle: staphylococcal infection around or within a hair follicle.
Carbuncle: staphylococcal infection of adjacent hair follicles (i.e. multiple boils/furuncles).
pustule vs abscess
Abscess: a localised accumulation of pus.
Pustule: a pus-containing lesion less than 0.5cm in diameter.
most common causative organism boils/carbuncle/abscess
staph aureus
may be MRSA or PVL-SA
when should you take a swab of boils/carbuncles/abscess
Consider taking a swab of pus from the contents of the lesion if:
The boil or carbuncle is:
Not responding to treatment.
Persistent or recurrent, to exclude atypical mycobacteria or Panton-Valentine leukocidin Staphylococcus aureus (PVL-SA).
There are multiple lesions.
The person:
Is immunocompromised.
Is known to be colonized with MRSA.
Has diabetes.
Is a member of a household, or resides in an institutional setting, where recurrent outbreaks of skin and soft tissue infections have been reported (to exclude PVL-SA).
management boil/caruncle/abscess?
- urgent same-day incision and drainage if large
- admit for IV abx based on clinical judgement eg systemically unwell or on face or immunocompromised
if not req ref or admis
1. prescribe 7-day abx if fever, cellulitis, sev pain, co-morbidities, on face
+ advise apply moist heat tds to hasten drainage of pus and alleviate pain
+ once drained, cover with steruke dressing
+ safety net
abx
Flucloxacillin is recommended first line (erythromycin [preferred in pregnancy and breastfeeding] or clarithromycin are alternatives if the person has a true allergy to penicillin)
what is the most common site of s.aureus colonisation
nose
when might you consider staph aureus carriage and decolonisation?
what do you do to investigate?
recurrent boils/abscesses or infections caused by s.aureus
Take swabs from the contents of the boil or carbuncle.
If recurrent boils or carbuncles are localized to the facial area, swab the nasal cavity.
If the boils or carbuncles are more extensive, consider swabbing the perineum, groin, axillae, and umbilicus in addition to the nose.
process of s.aureus decolonization
Do not start decolonization until acute infection has resolved.
Eliminate nasal carriage by prescribing Naseptin® cream (chlorhexidine plus neomycin), four times a day for 10 days. Be aware that Naseptin® contains arachis oil (peanut oil) and should not be used by a person known to be allergic to peanuts or soya.
Use an antiseptic preparation (such as chlorhexidine 4% body wash/shampoo or Triclosan 2%) daily as liquid soap in the bath, shower, or sink for 5 days.
consider other options for sensitive skin/dermatological conditions
what infections should you specifically assess for in children with neck lump
measles
mumps
rubella
infectious mononucelosis
features measles
prodromal phase
irritable
conjunctivitis
fever
Koplik spots
typically develop before the rash
white spots (‘grain of salt’) on the buccal mucosa
rash
starts behind ears then to the whole body
discrete maculopapular rash becoming blotchy & confluent
desquamation that typically spares the palms and soles may occur after a week
diarrhoea occurs in around 10% of patients
what is measles?
RNA paramyxovirus
one of the most infectious known viruses
spread by aerosol transmission
infective from prodrome until 4 days after rash starts
incubation period = 10-14 days
invetsigations measles
IgM antibodies can be detected within a few days of rash onset
management of measles
mainly supportive
admission may be considered in immunosuppressed or pregnant patients
notifiable disease → inform public health
most common complication of measles
otitis media
most common cause of death following measles
pneumonia
complications measles
otitis media: the most common complication
pneumonia: the most common cause of death
encephalitis: typically occurs 1-2 weeks following the onset of the illness)
subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness
febrile convulsions
keratoconjunctivitis, corneal ulceration
diarrhoea
increased incidence of appendicitis
myocarditis
how should you manage a contact of measles who is unvaccinated against measles
give MMR within 72 hours
what is mumps?
Mumps is a caused by RNA paramyxovirus and tends to occur in winter and spring
Spread
by droplets
respiratory tract epithelial cells → parotid glands → other tissues
infective 7 days before and 9 days after parotid swelling starts
incubation period = 14-21 days
clinical features mumps?
fever
malaise, muscular pain
parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%
how effective is MMR at preventing mumps?
MMR vaccine: the efficacy is around 80%
management mumps
rest
paracetamol for high fever/discomfort
notifiable disease
complications mumps
orchitis - uncommon in pre-pubertal males but occurs in around 25-35% of post-pubertal males. Typically occurs four or five days after the start of parotitis
hearing loss - usually unilateral and transient
meningoencephalitis
pancreatitis
what is rubella?
Rubella is caused by the togavirus.
If contracted during pregnancy there is a risk of congenital rubella syndrome
outbreaks more common around winter and spring
the incubation period is 14-21 days
individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash
features rubella
prodrome, e.g. low-grade fever
rash: maculopapular, initially on the face before spreading to the whole body, usually fades by the 3-5 day
lymphadenopathy: suboccipital and postauricular
complications rubella
arthritis
thrombocytopaenia
encephalitis
myocarditis
what is the classic triad of infectious mononucleosis
sore throat, pyrexia and lymphadenopathy
features of infectious mononucleosis
sore throat, pyrexia and lymphadenopathy
Other features include:
malaise, anorexia, headache
palatal petechiae
splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture
hepatitis, transient rise in ALT
lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes
haemolytic anaemia secondary to cold agglutins (IgM)
a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis
diagnosis infectious mononucleosis
heterophil antibody test (Monospot test)
NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever.
when do symptoms resolve infectious mononucleosis
Symptoms typically resolve after 2-4 weeks.
management infectious mononucelosis
rest during the early stages, drink plenty of fluid, avoid alcohol
simple analgesia for any aches or pains
consensus guidance in the UK is to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture
Safety netting
If you get any severe symptoms such as difficulty breathing, severe abdominal pain then go to a&e
how does HIV seroconersion present?
glandular fever type illness
sore throat
lymphadenopathy
malaise, myalgia, arthralgia
diarrhoea
maculopapular rash
mouth ulcers
rarely meningoencephalitis
how does lymph node TB present?
A “cold abscess” is a firm painless abscess caused by TB, usually in the neck. They do not have the inflammation, redness and pain you would expect from an acutely infected abscess.
what is toxoplasmosis
Toxoplasma gondii is an obligate intracellular protozoan that infects the body via the gastrointestinal tract, lung or broken skin. It’s oocysts release trophozoites which migrate widely around the body including to the eye, brain and muscle. The usual animal reservoir is the cat, although other animals such as rats carry the disease.
How does toxoplasmosis affect immunocompetent patients?
Most infections are asymptomatic. Symptomatic patients usually have a self-limiting infection, often having clinical features resembling infectious mononucleosis (fever, malaise, lymphadenopathy). Other less common manifestations include meningoencephalitis and myocarditis.
what causes cat scratch disease
Gram negative rod Bartonella Henselae
Cats become infected with Bartonella henselae from the bites of infected fleas or contact with infected blood
features of cat scratch disease
fever
History of cat scratch
Regional Lymphadenopathy
Headache, malaise
- one or more erythematous lesions at the site of inoculation, 3-12 days after scratch from a cat - most likely a kitten with fleas
- O/e: crusted papeles or, rarely, a pustule
- 1-3 weeks after primary lesion, regional lymphadenopathy appears, usually next to innoculation site - painful and may suppurate
- Systemic symptoms: fever malaise, headache, anorexia
complications cat scratch
aseptic meningitis
Encephalopathy
Prolonged fever
Myelitis, paraplegia, cerebral arthritis
Joint pain
Back pain
If innoculation directly into eye —> unilateral granulomatous conjunctivitis
Neuroretinitis
Abdominal pain (hepatitis/splenitis)
management cat scratch disease
supportive - antipyretics and analgesia
may need fluctulant tender nodes aspirated
Antibiotics are indicated in immunocompromised patients and atypical cases involving severe or systemic disease
Patients should follow up in 2-6 months for confirmation of symptom resolution.
prevention of cat scratch disease
Vigilant elimination of fleas from cats.[12]
Avoiding traumatic injury from cats, especially kittens. Cat-scratches and bites should be washed immediately and cats should not be allowed to lick open wounds
what are the stages of lyme disease
Stage 1: inoculation and localised infection
PC; erythema migrans
Stage 2: dissemination
joints, heart, nervous system
PC: flu-like illness, headache, feve, tiredness, n&v
PC: facial nerve palsy, meningitis, encephalitis, peripheral mononeuritis
PC: migratory joint pain
PC: carditis with heartblock
Stage 3: late manifestations/ dysregualted host immune response
PC: chronic arthritis, encephalopathy or peripheral neuropathy, ‘post-Lyme syndrome’
what is lyme disease? causative organism?
transmitted by bite of infected Ixodes ticks
The risk of transmission increases with the duration of tick attachment, with the highest risk occurring after 36-48 hours.
Lyme disease is caused by the spirochete bacterium Borrelia burgdorferi,
investigations lyme disease
If considering testing for Lyme disease, speak to ID
Erythema migrans and a history of tick bite or likely exposure
Treat with oral abx for 2-3 weeks. DO NOT TEST
Discuss any other cases with ID
If high clinical suspicion - investigate but start treatment before results
- ELIZA
- Immunoblot
management lyme disease
Doxycycline or amoxicillin
what is kawasaki disease
Kawasaki disease is also known as mucocutaneous lymph node syndrome. It is a systemic, medium-sized vessel vasculitis. It affects young children, typically under 5 years. There is no clear cause or trigger. It is more common in Asian children, particularly Japanese and Korean children. It is also more common in boys.
key complication kawasaki disease
A key complication is coronary artery aneurysm.
symptoms and criteria for diagnosis kawasaki
Fever of ≥5 days’ duration associated with at least four of these five changes
4 of 5 of Crash & burn
Conjunctivitis (bilateral non-purulent)
Rash (polymorphous, priamarily truncal)
Adenopathy (cervical)
Strawberry tounge (criteria is MM - throat redness, dry lips, red lips)
Hands (swelling and erythema) or arms or legs (redness, swelling, peeling)
and Burn (5 or more days of fever)
Invetsigations kawasaki
Full blood count can show anaemia, leukocytosis and thrombocytosis
Liver function tests can show hypoalbuminemia and elevated liver enzymes
Inflammatory markers (particularly ESR) are raised
Urinalysis can show raised white blood cells without infection
Echocardiogram can demonstrate coronary artery pathology
disease course kawasaki
Acute phase: The child is most unwell with the fever, rash and lymphadenopathy. This lasts 1 – 2 weeks.
Subacute phase: The acute symptoms settle, the desquamation and arthralgia occur and there is a risk of coronary artery aneurysms forming. This lasts 2 – 4 weeks.
Convalescent stage: The remaining symptoms settle, the blood tests slowly return to normal and the coronary aneurysms may regress. This last 2 – 4 weeks.
management kawasaki disease
High dose aspirin to reduce the risk of thrombosis
IV immunoglobulins to reduce the risk of coronary artery aneurysms
Patients will need close follow up with echocardiograms to monitor for evidence of coronary artery aneurysms.
when should you use aspirin in children
Kawasaki disease is one of the few scenarios where aspirin is used in children.
Aspirin is usually avoided due to the risk of Reye’s syndrome.
what is required urgently when leukemia is a ddx for a presentation
An urgent full blood count
what are lymphomas ? types?
Lymphomas are a group of cancers that affect the lymphocytes inside the lymphatic system. These cancerous cells proliferate within the lymph nodes and cause the lymph nodes to become abnormally large (lymphadenopathy).
Hodgkin’s lymphoma: caused by proliferation of lymphocytes.
Non-hodgkin’s lymphoma: encompasses all other types of lymphoma including burkitts
Presentation symptoms lymphoma
PC:
Painless lymphadenopathy
Bone marrow involvement
Anaemia
Thrombocytopenia → purpura
Infections
B symptoms:
Unintentional weight loss
Night sweats
Pyrexia
Mass effect
If mediastinal lymph nodes are involved, this can compress the airway and lead to dyspnoea, chest pain, and dry cough. It may also cause superior vena cava obstruction.
Compression of the superior vena cava: shortness of breath and facial oedema
Compression of the external biliary tree: jaundice
Compression of the ureters: hydronephrosis
Bowel obstruction: vomiting and constipation
Impaired lymph drainage: chylous pleural or peritoneal fluid, or lymphoedema of the lower limbs
Specific symptoms
Alcohol induced pain = hodgkins
Pruritus = more common in hodgkins
Burkitt’s lymphoma: large abdominal mass and symptoms of bowel obstruction
when should you 2ww for susepcted lymphoma? when should it be done sooner?
- unexplained lymphadenopathy or splenomegaly for adults aged 25 years or more
- within 48 hours for children and young people up to and including 24 years of age
Initial investigations lymphoma
FBC (anaemia, thrombocytopenia, neutropenia, lymphocytosis)
U&E (acute kidney injury from obstructive nephropathy)
LFTs
LDH (often elevated in high grade lymphomas, but non-specific)
Viral screening tests (hepatitis B/C, HIV, HTLV-1)
Hodgkins blood tests:
Erythrocyte sedimentation rate (ESR): Non-specific but tends to be elevated and indicates a poorer prognosis when the ESR level is >50 mm/hour in patients without B symptoms or >30 mm/hour in those with B symptoms.
what imaging might you organise ?lymphoma
Chest x-ray
mediastinal adenopathy, pleural or pericardial effusions and parenchymal involvement
CT-PETchest abdo pelvis for staging
Diagnostic tests lymphoma
BIOPSY
1. excisional biopsy
Hodgkins = Reed-Sternberg cells (owl’s eye appearance), or other distinctive Hodgkin’s cells such as lacunar cells or popcorn cells.
If the lesion is in the lung or abdomen, a core needle biopsy is preferred
IMMUNOPHENOTYPING FOR NHL
FISH (fluorescence in situ hybridisation) is used to identify a MYC rearrangement (Burkitt’s lymphoma) in all people newly presenting with histologically high-grade B-cell lymphoma
If a MYC rearrangement is found, FISH is then used to identify the immunoglobulin partner and the presence of BCL2 and BCL6 rearrangements
what is a CT vs PET scan
The CT scan takes a series of x-rays from all around your body and puts them together to create a 3 dimensional (3D) picture.
The PET scan uses a mildly radioactive drug to show up areas of your body where cells are more active than normal.
therefore called PET-CT
staging imaging lymphoma?
CT chest abdomen pelvis or PET/CT
FDG-PET-CT imaging to confirm staging should be offered to people diagnosed with:
Stage I diffuse large B-cell lymphoma by clinical and CT criteria
Stage I or localised stage II follicular lymphoma if disease is thought to be encompassable within a radiotherapy field
Stage I or II Burkitt lymphoma with other low-risk features
what staging system is used to stage lymphoma? explain it.
Ann-Arbor
Stage 1: Confined to one region of lymph nodes.
Stage 2: In more than one region but on the same side of the diaphragm (either above or below).
Stage 3: Affects lymph nodes both above and below the diaphragm.
Stage 4: Widespread involvement including non-lymphatic organs such as the lungs or liver.
HL vs NHL- which is more common?
Non-hodgkins is more common
HL vs NHL - which has alcohol induced pain?
hodgkins
HL vs NHL which is associated with pruritis
HL
HL vs NHL - which is associated with extra-nodal disease? what does extra-nodal dsease mea?
Extra-Nodal disease more common in non-hodgkins
N!!!
gastric (dyspepsia, dysphagia, weight loss, abdominal pain)
bone marrow (pancytopenia, bone pain)
lungs
skin
central nervous system (nerve palsies)
HL vs NHL reed sternberg cells?
hodgkins
Mature B cells - Reed Sternberg cells
which lymphoma associated w increasing age?
non-hodgkins
hodgkins has bimodal age distribution
HL vs NHL which has continguous spread lymph nodes
hodgkins
