Crianças com linfadenopatia cervical significativa: análise clínico-patológica e papel da aspiração por agulha fina no contexto indiano / Children with significant cervical lymphadenopathy: clinicopathological analysis and role of fine-needle aspiration in Indian setup

OBJETIVO: Estudar o perfil clínico-patológico de crianças indianas com linfadenopatia cervical e o papel da citologia aspirativa por agulha fina com ênfase especial na tuberculose como causa. MÉTODOS: Foram incluídas 89 crianças com faixa etária de 10 meses a 12 anos, admitidas em nosso hospital de abril de 2004 a março de 2005. Todos os pacientes foram submetidos a completa avaliação clínica e investigativa em relação à linfadenopatia cervical. Medidas de desfecho incluíram estado clínico e a capacidade de testes convencionais em categorizar tipos diferentes de linfadenopatia e sua utilidade no diagnóstico de linfadenite tuberculosa. A variabilidade interobservador foi analisada através do teste de kappa, tendo boa concordância. RESULTADOS: A hiperplasia reativa foi o tipo mais comum de linfadenite, seguida da granulomatosa. Os linfonodos do triângulo posterior unilateral foram o grupo afetado com maior freqüência no grupo de linfadenopatia cervical tuberculosa. A aspiração por agulha fina, seguida da coloração de Ziehl-Neelsen, histopatologia e cultura em associação, obteve sucesso em realizar o diagnóstico em 85,7 por cento dos casos de etiologia tuberculosa. CONCLUSÕES: A aspiração por agulha fina é uma ferramenta diagnóstica valiosa no tratamento de crianças com apresentação clínica de linfonodos cervicais aumentados. A técnica reduz a necessidade de procedimentos mais invasivos e dispendiosos, principalmente em países em desenvolvimento.Cultura e histopatologia, entretanto, devem ser consideradas em casos nos quais a citologia aspirativa por agulha fina não é diagnóstica.

OBJECTIVE: To study the clinicopathological profile of children from India with cervical lymphadenopathy and the role of fine-needle aspiration cytology with special emphasis on tuberculosis as a cause. METHODS: A total of 89 children in the age group of 10 months to 12 years, presenting to our hospital from April 2004 to March 2005, were included. All the patients underwent thorough clinical and investigational assessment vis-à-vis cervical lymphadenopathy. Outcome measurements included clinical status and ability of conventional tests to categorize different types of lymphadenopathy and their utility in diagnosing tubercular lymphadenitis. Interobserver variability was analyzed measuring kappa test and was found to be in agreement. RESULTS: Reactive hyperplasia was the most common type of lymphadenitis, followed by granulomatous involvement. Unilateral posterior triangle lymph nodes were the most commonly affected in the tubercular cervical lymphadenopathy group. Fine-needle aspiration followed by Ziehl-Neelsen staining, histopathology and culture in combination were able to perform the diagnosis in 85.7 percent of cases affected with tubercular etiology. CONCLUSIONS: Fine-needle aspiration is a valuable diagnostic tool in the management of children with the clinical presentation of enlarged cervical lymph nodes. The technique reduces the need for more invasive and costly procedures, especially in a Third World country. Culture and histopathology, however, should be considered in cases where repeated fine-needle aspiration cytology is non-diagnostic.

Cytodiagnosis of yolk sac tumor.

To analyze cytomorphologic features of yolk sac tumors of childhood. Four cases of pediatric yolk sac tumor (YST), diagnosed by fine needle aspiration cytology were reviewed (1998-2002). Age of patients ranged from 1(1/2) to 5 years. Three cases presented clinically with an intra-abdominal mass while one case presented with a testicular mass. Fine needle aspirates had been obtained directly as well as under radiologic (USG/CT) guidance. Smears were stained with H & E and Papanicolaou stain. In all cases values of serum alpha-fetoprotein and hCG were available preoperatively. Histopathologic diagnosis was correlated with cytologic findings in all the cases. Cytologic examination showed richly cellular smears with a combination of morphological patterns. Characteristically, tumor cells were arranged in papillary groups, tight cell clusters and formed acinar structures. Cells showed enlarged, moderately pleomorphic, hyperchromatic nuclei and moderate amount of cytoplasm, some of which displayed cytoplasmic vacuolation, displacing the nuclei eccentrically. Preoperatively, serum alpha-fetoprotein level was raised in all cases. Histopathology confirmed the cytologic diagnosis. Yolk sac tumor is common among the germ cell tumors of pediatric age group which presents a spectrum of cytomorphologic features having important differences with other germ cell neoplasm, e.g. embryonal carcinoma. Clinicoradiologic features and tumor markers are additionally helpful for an accurate cytologic diagnosis.

Serum cortisol and prolactin response to surgical stress in infants and children.

In a prospective study on 40 infants and children undergoing elective surgery under general anaesthesia, serum cortisol and prolactin levels were compared to assess hormonal response to stress as regards to age, sex, length of surgery and anaesthetic techniques. The rise in serum cortisol was independent of age, sex, length of surgery and anaesthetic techniques while percentage rise in serum prolactin were more in females compared to males and significant post-induction surge irrespective of sex.

A prospective study of closure techniques of abdominal incisions in infants and children.

In a prospective study of layered versus mass closure of abdominal incisions in infants and children, 34 cases underwent wound closure by layered and mass closure technique on an alternate basis. All the patients were assessed for their nutritional status and haemoglobin level pre-operatively, and wound complications were compared with respect to closure technique, nutritional status and normal haemoglobin level. Presence of protein energy malnutrition and anaemia did not increase the risk of wound complications with either of the technique.

Peri-anesthetic management of tracheo-esophageal fistula.

During a 3-year period 11 neonates underwent general anesthesia for primary repair of tracheo-esophageal fistula (TEF). The age ranged from 1-10 days. Out of these patients, 8 (72.7%) had atresia of the esophagus with a blind upper pouch and lower segment communicating with a trachea. A total of 7 patients (63.6%) had aspiration pneumonitis pre-operatively. Intubation was difficult in 3 (27.3%). There was no intraoperative mortality. However, the incidence of post-operative mortality was 27.3% (3 cases). The cause of death in all these cases was severe non-resolving pneumonia.

Gastroesophageal reflux in infants and children.

Seventy-five infants and children presenting during the period December 1984 to December, 1987 with the clinical features of vomiting, failure to thrive, chronic cough, recurrent pneumonia and atypical asthma were evaluated for gastroesophageal reflux by standard barium esophagram. Fifty six cases (74.7%) and as many as 80% of the infants studied had gastroesophageal reflux; Grade II reflux was seen in 12 cases, Grade III in 30 and Grade IV in 14 cases. The patients with gastroesophageal reflux were put on medical treatment. All the patients had subjective improvement after 6 weeks to 6 months of conservative treatment and none of them developed further complications of gastroesophageal reflux during a follow-up period varying from two months to fifteen months. Anti-reflux surgery was not considered owing to the subjective improvement in all the patients on conservative treatment. We conclude that gastroesophageal reflux is very common in infants and children and urge the need to evaluate the patients presenting with the symptoms suggesting gastroesophageal reflux by barium esophagram; conservative treatment is the mainstay in the management of these children.