Lymph Node Enlargement in Childhood

Lymph nodes are bean-shaped organs rich in immune system cells. The main function of lymph nodes is to filter microorganisms from the circulation, to help the immune system perform its function, and to prevent injuries in a local (regional) area from spreading throughout the body by contributing to their treatment within their own region. There are generally about 600 lymph nodes in our body, each measuring 0.5-1 cm in size.

Whether a lymph node is considered abnormal varies according to its location:

In the head and neck (cervical) region, larger than 1.5 cm (in young children, larger than 2 cm)

In the elbow (epitrochlear) lymph node, larger than 0.5 cm

In the chest cavity (mediastinum) and groin (inguinal) region, larger than 1.5 cm,

In the abdomen, they must be larger than 2 cm.

Enlargement of lymph nodes most often develops due to infections. By region:

Most commonly in the head and neck region (55%),

Generalized (25%),

In the groin and abdomen (14%),

In the armpit (5%)

Above the collarbone (supraclavicular region) it is seen at a rate of 1%.

The most important clue in identifying the cause of lymph node enlargement is the history obtained from the patient. In the history:

The duration of lymph node enlargement,

Accompanying findings and symptoms (fever, joint/bone pain, rash, weight loss, night sweats, itching, shortness of breath),

Infections experienced within the last month,

Travel history,

Contact with animals,

Tuberculosis

Medication and vaccination history must definitely be inquired about

The most important clue in identifying the cause of lymph node enlargement is the physical examination. The size and location of the lymph node, whether it is unilateral or bilateral, whether it is firm or soft, whether it shows fluctuation (undulation) on manual examination, and whether it is adherent to surrounding structures are extremely important. Supraclavicular LAP has the highest likelihood of being malignant (cancerous) and should always be considered pathological. Lymph node enlargements are divided into three categories according to duration:

Acute (0-3 weeks)

Subacute (3-6 weeks)

Chronic (longer than 6 weeks)

Reactive cervical (head and neck) lymph node enlargements secondary to viral infections

The most common cause of cervical (head and neck) lymph node enlargement is viral infections. They are called lymphadenitis. Treatment: Viral cervical (head and neck) lymph node enlargements generally require only supportive care. However, viral lymph node enlargements may over time turn into suppurative or bacterial lymph node enlargements.

Acute Bacterial Lymphadenitis/Suppurative Lymphadenitis

It is the second most common cause of cervical lymph node enlargement in childhood. It is difficult to distinguish from viral lymphadenitis. If it does not begin to shrink within a week, bacterial or secondary bacterial lymph node enlargement is considered. Restriction of neck movements may occur. First-line treatment is amoxicillin+clavulanic acid. In cases not responding to treatment, broader-spectrum antibiotics can be used (Vancomycin, ceftriaxone IV). If fever does not subside by the 48th-72nd hour of treatment and fluctuation (undulation) is present on physical examination, an abscess should be considered. Abscesses:

If smaller than 1x1 cm, they do not require surgical drainage; antibiotics are sufficient

If smaller than 1.5-2 cm, at least 24-48 hours of IV antibiotic treatment may be required.

For larger ones, aspiration/drainage (surgical procedure) should be performed.

Subacute/Chronic lymph node enlargements

If lymph node enlargement lasts 3-6 weeks, subacute infection is referred to. The most common causes:

Cat scratch disease (B. henselae)

Toxoplasmosis

Viral infections (CMV, HIV)

Cat scratch disease is caused by the agent Bartonella henselae. Lymph nodes, especially in the armpit, may enlarge immediately or within weeks after a cat scratch. It may resolve on its own, but antibiotic use (azithromycin, clarithromycin, ciprofloxacin) may also be required. In non-responding cases, surgical resection may be performed.

Non-infectious causes can also be seen in cervical LAP. These are grouped under three main headings:

Congenital (present from birth) benign neck masses

Malignancy (cancer)

Other non-infectious causes

Not every lymph node enlargement should be attributed to infection; especially in prolonged lymph node enlargements accompanied by additional complaints, causes related to malignancy (cancer) must definitely be taken into consideration. The rate of cancer in lymph node enlargements seen in the head and neck region in children is approximately 2-5%. In children, the types of cancer seen in lymph node enlargements due to cancer vary by age group:

Before age 6, the following are the most common:

Acute lymphoblastic/myeloid leukemia

Non-Hodgkin lymphoma

Neuroblastoma

After age 6, first place is taken by:

Hodgkin lymphoma takes first place

In acute lymphoblastic leukemia and acute myeloblastic leukemia:

Generalized lymph node enlargement is common

Lymph node enlargements are rapid and firm in consistency

Accompanying findings are usually present

Fever, pallor, weakness, easy bruising, nose and gum bleeding, petechiae (small subcutaneous hemorrhages)

In leukemias, definitive diagnosis is made with bone marrow aspiration/biopsy and special tests called flow cytometry

In lymphomas, the nodes may be firm and rubbery, painless, and night sweats called B symptoms, persistent fever and weight loss may be seen.

Biopsy indications

Many lymph node enlargements can be treated in a short time. However, in some lymph node enlargements your doctor may decide on a biopsy. Situations requiring a biopsy from a child with lymphadenopathy are as follows:

Suspicion of malignancy (if suspicion arises in light of history, physical examination, and accompanying findings)

Lymph node enlargements that do not resolve within 4-6 weeks

Lymph node enlargements that continue to grow regularly within 2-3 weeks

Lymph node enlargements larger than 2.0 cm' and unresponsive to treatment

Presence of findings suggestive of cancer on ultrasound or tomography

In conclusion, in early life, in children exposed to environmental viral and bacterial stimuli, lymph node enlargements are mostly due to infections. Treatment can easily be carried out in cooperation with the family doctor. In very rare cases, it should be kept in mind that they may also be due to non-infectious causes. Therefore, staying calm, early doctor examination, and, when necessary, diagnosis, treatment and follow-up that may be long-term are extremely important.