Pediatric emergency medicine trisk 672

effusion may obscure a mass on both chest x-ray and chest CT scan. Malignant
pericardial effusions are most often associated with leukemias and lymphomas. For
general diagnosis and management of pulmonary and pericardial effusions see
Chapters 86 Cardiac Emergencies and 99 Pulmonary Emergencies . Askin tumor or
metastatic sarcomas may present as a chest wall mass with or without pain. More
commonly, it presents with respiratory symptoms from an effusion.


TABLE 98.5
LYMPHOMA PRESENTATIONS AND CONSIDERATIONS IN THE ED


Lymphoma

Typical presentation

Potential complications at
diagnosis and
considerations for ED
management

Hodgkin disease

Painless, hard adenopathy:
neck and supraclavicular
common
AMM common, with or
without symptoms
Pleural effusions uncommon
May have “B” symptoms
Fevers

Night sweats
Weight loss (at least 10%
weight loss)

Superior vena cava (SVC)
syndrome
Tracheal obstruction

Lymphoblastic
lymphoma

Painless, hard adenopathy at
any site
Respiratory symptoms from
rapidly growing
mediastinal mass, often
with pleural effusions (Tlineage, advanced stage)
GI tract involvement rare

Tumor lysis syndrome (TLS)
SVC syndrome
Tracheal obstruction
Pleural effusions

Burkitt lymphoma

Single site of enlarged
lymphoid tissue (low
stage)
Incidental finding on

appendectomy
Asymmetric enlarged
tonsil
Lead point for
intussusception in >3 yrs
A single, painless enlarged
node
Painless, hard adenopathy
with rapid growth (usually
advanced stage)

Rapid assessment for TLS:
High risk of severe tumor
lysis, even prior to
treatment (advanced stage)
First dose rasburicase in ED
if uric acid >8 and low risk
for G6PD deficiency
Urgent consultation with
oncology
Admission to center with
available pediatric dialysis


Rapidly progressing
abdominal distention with
diffuse involvement of the
GI tract/liver with ascites
and pleural effusions
(advanced stage)

Diffuse large B-cell Painless, hard adenopathy at
lymphoma
any site,
neck/supraclavicular
common
AMM common, symptoms
variable (advanced)
Symptom progression can be
rapid (advanced stage)
Systemic symptoms of
malaise, weight loss
common with advanced
disease
GI symptoms/abdominal
mass from GI tract and
mesenteric nodes
involvement
Anaplastic large cell Painless, hard adenopathy at
lymphoma
any site
Skin/subcutaneous nodules
GI symptoms/abdominal
mass from GI tract and
mesenteric node
involvement
Systemic symptoms (fevers,
night sweats, weight loss,
malaise) common with
advanced disease

TLS
SVC syndrome
Tracheal obstruction

TLS

AMM, anterior mediastinal mass; G6PD, glucose-6-phosphate dehydrogenase.

Clinical Assessment
There may be useful clues to the diagnosis from the history and physical
examination. A recent history of new-onset asthma in an older child who responded