Cervical lymphadenopathy in children: a diagnostic tree analysis model based on ultrasonographic and clinical findings.

OBJECTIVES: To establish a diagnostic tree analysis (DTA) model based on ultrasonography (US) findings and clinical characteristics for differential diagnosis of common causes of cervical lymphadenopathy in children. METHODS: A total of 242 patients (131 boys, 111 girls; mean age, 11.2 ± 0.3 years; range, 1 month-18 years) with pathologically confirmed Kikuchi disease (n = 127), reactive hyperplasia (n = 64), lymphoma (n = 24), or suppurative lymphadenitis (n = 27) who underwent neck US were included. US images were retrospectively reviewed to assess lymph node (LN) characteristics, and clinical information was collected from patient records. DTA models were created using a classification and regression tree algorithm on the basis of US imaging and clinical findings. The patients were randomly divided into training (70%, 170/242) and validation (30%, 72/242) datasets to assess the diagnostic performance of the DTA models. RESULTS: In the DTA model based on all predictors, perinodal fat hyperechogenicity, LN echogenicity, and short diameter of the largest LN were significant predictors for differential diagnosis of cervical lymphadenopathy (overall accuracy, 85.3% and 83.3% in the training and validation datasets). In the model based on categorical parameters alone, perinodal fat hyperechogenicity, LN echogenicity, and loss of fatty hilum were significant predictors (overall accuracy, 84.7% and 86.1% in the training and validation datasets). CONCLUSIONS: Perinodal fat hyperechogenicity, heterogeneous echotexture, short diameter of the largest LN, and loss of fatty hilum were significant US findings in the DTA for differential diagnosis of cervical lymphadenopathy in children. KEY POINTS: • Diagnostic tree analysis model based on ultrasonography and clinical findings would be helpful in differential diagnosis of pediatric cervical lymphadenopathy. • Significant predictors were perinodal fat hyperechogenicity, heterogeneous echotexture, short diameter of the largest LN, and loss of fatty hilum.

Topical steroids eye drops in conjunctival reactive lymphoid hyperplasia: Case report.

RATIONALE: Conjunctival lymphoproliferative lesions constitute a significant diagnostic challenge and it is essential to exclude neoplastic lesions. Histopathological and immunohistochemical tests are very useful in establishing the correct diagnosis. Reactive lymphoid hyperplasia (RLH) is part of a spectrum of lymphocytic infiltrative disorders. Evidence is scarce regarding appropriate treatment of conjunctival RLH. We report a case treated with topical corticosteroid. PATIENT CONCERNS: A 40 year-old female presented with a 7-month history of a slow growth tumor in the superior conjunctiva of the right eye. Slit-lamp examination demonstrated salmon colored lesion in the upper conjunctiva, with little conjunctival injection, but no significant neovascularization. There was no eyelid involvement. DIAGNOSES: Ultrasound biomicroscopy showed lesion depth (1.53 mm) and larger diameter (10.73 mm). Pathological examination revealed a chronic inflammatory process with conjunctival folicular hyperplasia. The immunohistochemistry examination showed predominance of CD20, CD23, and CD 3 e CD 5. INTERVENTION: We started topic prednisolone 1% 6 times daily. OUTCOMES: Six months after starting treatment, the lesion completely resolved, without any side-effects or recurrence during three-year follow-up period. LESSONS: Conjunctival RLH can be managed in various ways, depending on patient symptonm, comorbities, and disease distribution. Surgical resection with cryotherapy, radiotherapy, systemic corticosteroids, subconjunctival triamcinolone, and rituximab are some options. There is no strong evidence in the literature of conjunctival RLH successfully treated with topical eye drops corticosteroid. In this report, we obtained completely resolution of conjunctival RLH with topical corticosteroid. CONCLUSION: Topical eye drops corticosteroids are an alternative treatment for selected cases of conjuncitval RLH with no orbital or eyelid involvement.

Clinical spectrum of skin manifestations of Lyme borreliosis in 204 children in Austria.

The spectrum of skin manifestations of Lyme borreliosis in children is not well characterized. We conducted a retrospective study to analyze the clinical characteristics, seroreactivity to Borrelia burgdorferi sensu lato, and outcome after treatment in 204 children with skin manifestations of Lyme borreliosis seen in 1996-2011. Solitary erythema migrans was the most common manifestation (44.6%), followed by erythema migrans with multiple lesions (27%), borrelial lymphocytoma (21.6%), and acrodermatitis chronica atrophicans (0.9%). A collision lesion of a primary borrelial lymphocytoma and a surrounding secondary erythema migrans was diagnosed in 5.9% of children. Rate of seroreactivity to B. burgdorferi s.l. was lower in solitary erythema migrans compared to other diagnosis groups. Amoxicillin or phenoxymethylpenicillin led to complete resolution of erythema migrans within a median of 6 (solitary) and 14 days (multiple lesions), respectively, and of borrelia lymphocytoma within a median of 56 days. In conclusion, erythema migrans with multiple lesions and borrelial lymphocytoma appear to be more frequent in children than in adults, whereas acrodermatitis chronica atrophicans is a rarity in childhood. The outcome after antibiotic therapy was excellent in children, and appears to be better than in adults.

Hepatic pseudolymphoma: imaging-pathologic correlation with special reference to hemodynamic analysis.

OBJECTIVES: To clarify radiological findings and hemodynamic characteristics of hepatic pseudolymphoma, as compared with the histopathological findings. METHODS: Radiological findings of ten histopathologically confirmed hepatic pseudolymphomas in seven patients were examined using US, CT, and MRI. Six patients also underwent angiography-assisted CT, including CT during arterial portography (CTAP) and CT during hepatic arteriography (CTHA) to analyze hemodynamics. RESULTS: The nodules were depicted as hypoechoic on US, hypodense on precontrast CT, hypointense on T1-weighted images, and hyperintense on T2-weighted images. On contrast-enhanced CT/MRI, they showed various degrees of enhancement, and sometimes, perinodular enhancement was observed at the arterial dominant and/or equilibrium phase. On CTAP, the nodules showed portal perfusion defects, including some in the perinodular liver parenchyma. On CTHA, irregular bordered enhancement was observed in perinodular liver parenchyma on early phase, and continued until delayed phase. Some nodules had preserved intra-tumoral portal tracts. Histopathologically, the nodules consisted of marked lymphoid cells. In perinodular liver parenchyma, stenosis or disappearance of portal venules, caused by lymphoid cell infiltration in the portal tracts, was observed. CONCLUSIONS: Hepatic pseudolymphoma showed some characteristic radiological findings including hemodynamics on CT, MRI, and angiography-assisted CT. These findings are useful in the differentiation from hepatocellular carcinoma and other tumors.

Lymphocytic interstitial pneumonia and other benign lymphoid disorders.

Nonneoplastic pulmonary lymphoid disorders consist of a complex spectrum of diseases for pathologists and pulmonologists alike. Advances in our understanding of these disorders in recent years have led to revisions in the classification scheme. This review summarizes the clinicoradiological and pathological features of several benign pulmonary lymphoid disorders as well as the current knowledge regarding their pathogenesis. The disorders discussed include lymphocytic interstitial pneumonitis, follicular bronchiolitis, nodular lymphoid hyperplasia, inflammatory pseudotumor, Castleman disease, immunoglobulin G4-related disease in the lung, and posttransplant lymphoproliferative disease.

Microscopic mimicry of lymphomas: diagnostic pitfalls.

A common, critical challenge for the pathologist is the distinction between lymphoma and lymphoma simulators. Ancillary studies are effective in making this distinction and should be used in descending order of their likely reliability according to the particular differential diagnostic consideration at hand. Clinical case information is essential to avoid misinterpretation. Lymphoma simulators can be grouped into several major categories: nonlymphoid neoplasms, usually high-grade, simulating high-grade lymphomas; chronic lymphoid hyperplasias simulating low-grade lymphomas; and acute lymphoid hyperplasias simulating high-grade lymphomas.

Current aspects of Lyme disease and other Borrelia burgdorferi infections.

Lyme disease, acrodermatitis chronica atrophicans, and borrelial lymphocytoma are caused by species of the spirochete Borrelia burgdorferi. Lyme disease has emerged as the leading vector-borne infectious disease in the United States. This article presents a current review of these entities.

Drug-induced pseudolymphoma and drug hypersensitivity syndrome (Drug Rash with Eosinophilia and Systemic Symptoms: DRESS).

Since the first description by Saltzstein in 1959, the denomination of drug-induced pseudolymphoma was used to describe two cutaneous adverse drug reactions with a histological picture mimicking malignant lymphoma. On the basis of clinical presentation, this term includes two different patterns: (1) hypersensitivity syndrome which begins acutely in the first 2 months after the initiation of the drug and associates fever, a severe skin disease with characteristic infiltrated papules and facial edema or an exfoliative dermatitis, lymphadenopathy, hematologic abnormalities (hypereosinophilia, atypical lymphocytes) and organ involvement such as hepatitis, carditis, interstitial nephritis, or interstitial pneumonitis. The cutaneous histological pattern shows a lymphocytic infiltrate, sometimes mimicking a cutaneous lymphoma, and the mortality rate is about 10%. When organ involvement exists, corticosteroids are often prescribed with dramatic improvement. Relapses may occur. (2) drug-induced pseudolymphoma which has a more insidious beginning with nodules and infiltrated plaques appearing several weeks after the beginning of the drug without constitutional symptoms. A pseudolymphoma pattern is seen on cutaneous histological slides. Complete improvement is usual after drug withdrawal, but a delayed lymphoma is possible. To decrease the ambiguity of the denomination of hypersensitivity syndrome, we propose the term of DRESS (Drug Rash with Eosinophilia and Systemic Symptoms).

Update on lymphoid interstitial pneumonitis.

Lymphoid interstitial pneumonitis (LIP) involves a clinicopathologic pattern of pulmonary disease characterized by diffuse interstitial reactive lymphoid infiltrates. In adults, it occurs most commonly in autoimmune diseases, such as Sjögren's syndrome (0.9% of these patients) and primary biliary cirrhosis, whereas in children it is usually seen in HIV infection. Dysproteinemias (hyper- and hypogammaglobulinemia) are found in more than 60% of patients. Children can show CD8-lymphocytosis in bronchoalveolar lavage fluid, lung tissue, peripheral blood, and salivary gland, associated with HLA-DR5 haplotype. Radiographically, most patients with LIP have reticulonodular infiltrates, with or without patchy areas of consolidation. CT scans can show both small nodular and ground glass patterns, patterns that are diagnostically nonspecific. Reduced lung volumes and diffusing capacities are consistent and sensitive indicators of disease in LIP. In an experimental model, diffusing capacity was the single most sensitive functional index of disease progression. Microscopically, LIP is part of a spectrum of pulmonary lymphoid proliferations, ranging from follicular bronchitis-bronchiolitis and pulmonary lymphoid hyperplasia (the latter in AIDS patients), proliferations largely limited to airways, to low-grade malignant lymphoma. These patterns may be difficult to differentiate from each other. It appears that LIP sometimes evolves to lymphoma; the frequency of this evolution is probably low but is difficult to assess because low-grade lymphomas may mimic LIP. A relatively high frequency of LIP patients have Epstein-Barr virus DNA in their lungs but not all patients with LIP show this finding, suggesting other possible etiologies.