Retinoblastoma mnemonic this month. Plus information on lower sugar content recipes for the reintroduction of cows milk into a child’s diet, labial adhesions, 6 in 1 vaccine and don’t miss infantile spasms as early treatment improves overall prognosis. Do leave comments below.
Children’s cancer information this month – prevalence and red flags, a link to the excellent immunisation resource – Oxford vaccine group – for all those questions about individual immunisations that you can’t always answer, NICE’s recent UTI update and infant dyschezia. Do leave comments below.
More musings from Dr Waterfield this month – this time on paracetamol for immunisation discomfort. Also the 7 important features of a headache y0u must ask about, a link to a very good paediatric emergency medicine site, NICE quality standards in depression, molluscum contagiosum and more musings from me, this time on paediatric phlebotomy. Do leave comments below.
BCG Lymphadenitis with thanks to Dr Mujahid Hassan
Lymphadenitis is the most common complication of BCG vaccination, and is of two types – suppurative and non-suppurative.
Normal course post-vaccination:
Intradermal injection -> local multiplication of vaccine -> transport to lymphatics via lymph glands -> haematogenous dissemination of BCG.
No clear definition of ‘BCG lymphadenitis,’ proposed definition is when it becomes palpable or concerning for parents.
Can appear as early as two weeks after vaccination, most within 6 months and almost all cases will be within 24 months.
Normally ipsilateral with one or two palpable lymph nodes, but can involve multiple nodes. Normally axillary but can be with cervical/supraclavicular.
- Isolated lymph node enlargement
- BCG vaccination to ipsilateral side
- Absence of tenderness or heat to lump
- Absence of fever
Non-suppurative will resolve within a few weeks – this is a normal reaction and most of these are sub-clinical so go unnoticed.
Suppurative involves an enlarging lymph node with fluctuant appearances, oedema and erythema. Happens in ’30-80%’ of cases of lymphadenitis.
Treatment of suppurative lymphadenitis:
Antibiotics: Previously erythromycin/rifampicin/isoniazid have been used but their clinical role is of dubious significance, so are not used routinely.
Reassurance and followup are what is needed.
Fine Needle Aspiration: Suppurative lymphadenitis can result in spontaneous perforation and sinus formation, which can result in several unpleasant months of dressing and wound care. FNA is thus recommended to prevent this and reduce time for healing.
Surgical excision: Risks of general anaesthesia – other than in extreme cases of failed FNA/multiloculated lymph nodes – far outweigh the potential benefits.
Management pathway and images courtesy of:
WM Chan, YW Kwan, CW Leung. Management of Bacillus Calmette-Guérin Lymphadenitis, Hong Kong Journal of Paediatrics (New Series). Vol 16. No. 2, 2011, available via http://www.hkjpaed.org/details.asp?id=782&show=1234
J Goraya and V Virdi, Bacille Calmette-Guérin lymphadenitis, Postgrad Med J. 2002 June; 78(920): 327–329,
available via http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742390/pdf/v078p00327.pdf