A 3-year-old boy is brought to clinic by his mother due to fevers. Three weeks ago, the patient developed a fever, cough, and runny nose. He attends day care, where several children have had viral upper respiratory infections. Symptoms had briefly resolved 10 days ago, but the fever recurred last week after the patient returned to day care. Since then, he has been home due to fever occurring almost daily despite acetaminophen administration. Temperature is 38.3 C (100.9 F). Examination shows enlarged lymph nodes in the neck region. Lymphadenopathy at which of the following locations is most concerning for malignancy rather than infection in this patient?

Question

A 3-year-old boy is brought to clinic by his mother due to fevers.  Three weeks ago, the patient developed a fever, cough, and runny nose.  He attends day care, where several children have had viral upper respiratory infections.  Symptoms had briefly resolved 10 days ago, but the fever recurred last week after the patient returned to day care.  Since then, he has been home due to fever occurring almost daily despite acetaminophen administration.  Temperature is 38.3 C (100.9 F).  Examination shows enlarged lymph nodes in the neck region.  Lymphadenopathy at which of the following locations is most concerning for malignancy rather than infection in this patient?

Quizplus · Accepted Answer

11ec160b_3af4_dd8c_9249_191d970f2e63_MD0001_00 Lymph node enlargement (lymphadenopathy) of the head and neck is common in children due to frequent exposure to infections (eg, pharyngitis, upper respiratory infections). The lymphatic system drains bacteria and cellular debris through local lymph nodes, which filter foreign material and contain lymphocytes to fight infection. Lymph then drains to the thoracic and right lymphatic ducts, which empty into the subclavian veins. Although lymphadenopathy usually occurs secondary to the proliferation of inflammatory cells in response to infection, it is less commonly due to a clonal expansion of malignant cells. Malignancy should be suspected when lymph node enlargement is associated with any of the following features: The supraclavicular nodes drain the chest (ie, pulmonary system, mediastinum) and abdomen (ie, gastrointestinal and genitourinary tracts). Therefore, enlargement of these lymph nodes is unlikely to be caused by common childhood infections and always warrants further workup (eg, complete blood count, ultrasound) for an associated malignancy. (Choices A and B) Anterior and posterior cervical lymphadenopathy is common with upper respiratory infections because these nodes drain the neck and oropharynx. (Choices C and D) The submandibular nodes drain the cheeks, lips, gums, and part of the tongue. The submental nodes drain the floor of the mouth and part of the lower lip. These nodes are commonly enlarged with infections affecting the oral cavity, including dental infections and common viral infections (eg, coxsackievirus). Educational objective: Lymph node enlargement is most commonly due to infection-triggered cellular proliferation but can be caused by clonal expansion of malignant cells. Enlargement of the supraclavicular lymph nodes, which drain the chest and abdomen, is unlikely to be caused by common childhood infections and is concerning for malignancy.

A 3-Year-Old Boy Is Brought to Clinic by His Mother