儿童纵隔淋巴结病(ML)可由恶性肿瘤引起,感染,或者风湿性疾病,并且可能在影像学检查中或在各种症状的检查中偶然发现。我们的目的是描述在该国流行地区出现ML的三级护理中心的儿童的组织胞浆菌病的临床表现和自然史。
机构审查委员会批准后,对所有已证实(阳性血清学)或疑似组织胞浆菌病(阴性血清学,结核病检测阴性,和随访中的良性结局)在5年内进行。测试了74例患者;排除了其他诊断(n=6)或无ML(n=26)的患者,总共44名患者。人口统计,临床表现,症状,实验室数据,疗程,射线照相研究,并对住院和门诊就诊进行了检查。
在44名ML患者中,27人被证实有组织胞浆菌病,19例疑似组织胞浆菌病。影像学或临床检查的中位随访时间为6.9mo(0.3-73.2mo)。16例患者接受伊曲康唑抗真菌治疗,15名患者接受了至少一个疗程的类固醇治疗,几乎所有的呼吸道症状;11例患者(24%)接受了这两种治疗。接受抗真菌药的患者与未接受抗真菌药的患者之间的再入院率(n=5对2,P=0.7)或症状复发(n=2对5,P=0.4)没有差异。接受类固醇治疗与气道狭窄和更高的再入院率相关(n=6,而未接受类固醇治疗的2,P=0.04),但没有症状复发。进行了9个淋巴结或肿块活检;然而,病理仅在3例患者中证实了非特异性感染,其余6例患者未诊断.27例患者至少有一项组织胞浆菌病的确认性实验室测试呈阳性。44例患者中有39例(84%)被诊断为组织胞浆菌病(证实或怀疑)通过1-2个月的随访无症状,其余有间歇性胸痛或反应性气道疾病。
由于已证实或疑似组织胞浆菌病的ML通常是一种自限性疾病,可以通过治疗儿童的症状来控制。抗真菌药和类固醇的益处不明确,可能不会改变疾病的自然进程。活检在ML的设置中很少诊断,和侵入性程序应避免。
Mediastinal lymphadenopathy (ML) in children can arise from malignancy, infection, or rheumatic illness among others, and may be found incidentally on imaging or during workup for a variety of symptoms. Our aim was to describe the clinical presentation and natural history of histoplasmosis in children who present to a tertiary care center with ML in an endemic area of the country.
After institutional review board approval, a retrospective study of all children (aged < 21 y) presenting with proven (positive serologies) or suspected histoplasmosis (negative serologies, negative tuberculosis testing, and benign outcomes in follow-up) over a 5-y period was done. Seventy-four patients were tested; those with another diagnosis (n = 6) or without ML (n = 26) were excluded, for a total cohort of 44 patients. Demographics, clinical presentation, symptoms, laboratory data, treatment course, radiography studies, and inpatient and outpatient visits were examined.
Of the 44 patients with ML, 27 had proven histoplasmosis, and 19 had suspected histoplasmosis. The median follow-up by imaging or clinical examination was 6.9 mo (0.3-73.2 mo). Sixteen patients received antifungal therapy with itraconazole, and 15 patients received at least one course of steroids, nearly all for respiratory symptoms; 11 patients (24%) received both. There was no difference in readmission rate (n = 5 versus 2, P = 0.7) or recurrence of symptoms (n = 2 versus 5, P = 0.4) between patients who received an antifungal and those that did not. Receiving steroid therapy was associated with airway narrowing and a higher readmission rate (n =6 versus 2 who were not treated with steroids, P = 0.04), but not with symptom recurrence. Nine lymph node or mass biopsies were performed; however, the pathology only confirmed nonspecific infection in three and was nondiagnostic in the remaining six patients. Twenty-seven patients had at least one confirmatory laboratory test positive for histoplasmosis. Thirty-nine of the 44 patients (84%) with a diagnosis of histoplasmosis (proven or suspected) were asymptomatic by 1-2 mo follow up, with the remainder having intermittent chest pain or reactive airway disease.
ML because of proven or suspected histoplasmosis is usually a self-limiting disease that can be managed with treatment of the child\'s symptoms. Antifungals and steroids are of unclear benefit and may not alter the natural course of the disease. Biopsies are rarely diagnostic in the setting of ML, and invasive procedures should be avoided.