Management Outcomes of Lymphadenopathy among the Children

Background : Lymphadenopathy refers to the enlargement of lymph nodes due to various causes, and its appropriate management is crucial for optimal patient outcomes. Objective: To analyze the onset of lymphadenopathy (LAP) in children in terms of gender and age, explore its clinical manifestations and the specific lymph node areas affected, identify prevalent causes, and assess the outcomes of various treatment approaches. Patients and Methods: This cross-sectional study conducted between October 2021 and March 2023 at Rapareen Teaching Hospital for Children in Erbil City, which examined the lymphadenopathy in 40 children . The study included children aged 0-15 years with a lymphadenopathy diagnosis. Data collection involved recording demographic information, lymphadenopathy site and characteristics, clinical symptoms, antibiotic usage and response, reactive diagnoses, and treatment outcomes. Additional laboratory measurements were also taken. The collected data were analyzed using descriptive statistics, statistical tests, and logistic regression analysis. The study adhered to ethical principles, obtained informed consent, and ensured data confidentiality. Results: The mean age of the children was 3.397 ± (2.192) years. 23 (59%) children had a single lymphadenopathy, and 16 (41%) had multiple lymphadenopathies. The most common site of lymphadenopathy with a frequency of 10 (25%) was in the posterior cervical region, while 7 (17.5%) was observed in the submental area. 38 (95%) children received antibiotic treatment. Out of this number, 23 (60.5%) responded positively to the treatment, while 15 (39.5.5%) did not respond. Conclusion: The results of this study showed that in the patients who were treated with antibiotics, the drug was able to lead to some degree of recovery.


Introduction
Lymphadenopathy refers to the enlargement or swelling of lymph nodes, which are small, bean-shaped organs located throughout the body.Lymph nodes are important components of the immune system because they filter lymph fluid and trap dangerous substances such as bacteria, viruses, and cancer cells [1,2].
Lymphadenopathy can develop as a result of a variety of factors, including infections, autoimmune illnesses, cancer (such as lymphoma or metastatic cancer), and other ailments.It might affect individual lymph nodes or several lymph nodes across the body [1,3].
Lymphadenopathy presents with various symptoms, such as tender or painful swollen lymph nodes, fever, fatigue, night sweats, and weight loss [9,10].Physical examinations, blood tests, imaging investigations (ultrasound or CT scans), and occasionally a biopsy of the afflicted lymph node are used by medical specialists to diagnose and pinpoint the source of it [5,11].The underlying cause and degree of lymphadenopathy determine the course of treatment.Antibiotics, antivirals, and antifungals are frequently used to treat infections.
Autoimmune-related lymphadenopathy may require immunosuppressive medications.Chemotherapy, radiation treatment, or surgery could be used to treat lymphadenopathy linked with cancer [1,12,13].
Accurate statistics on the epidemiology of lymphadenopathy are not available, but what is known is that most people with lymphadenopathy have a benign cause.Since age is an important aspect in describing the epidemiology of lymphadenopathy, it may be divided into children and adults.In children, the majority of cases are benign, with reactive hyperplasia of the unknown cause being the most common, followed by granulomatous infections, cancer, and dermatopathic lymphadenopathy.Although most of the cases of lymphadenopathy in children are benign and self-limiting, identifying the underlying reasons is critical in order to commence appropriate therapy and management methods [1,14].
Lymphadenopathy is a frequent ailment in children, and understanding how it is controlled and been critical for healthcare practitioners to give appropriate therapy.However, there has been little research on this subject, particularly in Erbil, making our study critical in bridging this knowledge gap.This study may provide significant insights into the prevalence, etiology, and treatment choices for lymphadenopathy in children, which might inspire future research and improve healthcare practices.The aim of this research was to analyze the onset of lymphadenopathy (LAP) in children in terms of gender and age , explore its clinical manifestations and the specific lymph node areas it affected, identify prevalent causes, and assess the outcomes of various treatment approaches.

Study Design and Population
This cross-sectional study was conducted between October 2021 and March 2023 on 40 children with lymphadenopathy referred to Rapareen Teaching Hospital for Children in Erbil City.

Inclusion and Exclusion Criteria
The criteria for entering the study were children aged 0-15 years with a diagnosis of lymphadenopathy, and having informed consent were included.Patients with incomplete medical records, a history of malignancy, immunodeficiency, or chronic disease, or those who did not perform necessary diagnostic tests were excluded from the study.

Data Collection
Data collection encompassed various demographic and clinical parameters.Gender, age, and duration of lymphadenopathy were recorded for each participant.The site of lymphadenopathy was classified into submental, axilla, posterior cervical, submandibular, or supraclavicular regions.Additionally, the number of lymphadenopathy nodes (single or multiple) and their corresponding sizes were documented.Clinical symptoms such as mass, fever, rigor, sore throat, and weight loss were assessed.Information on whether the children received antibiotics and their response to the antibiotics was also collected.Reactive diagnoses, including lymphadenitis, malignancy, tuberculosis (TB), infectious mononucleosis (IMN), and cytomegalovirus (CMV), were documented.Lastly, the outcome of the lymphadenopathy management was categorized as cured, exit from the study, or ongoing treatment.

Statistical Analysis
After collecting the data, the data were entered into SPSS version 26 and analyzed.Descriptive statistics were used to summarize the demographic and clinical characteristics of the study participants.Associations between variables were examined using appropriate statistical tests such as chi-square or Fisher's exact tests.Logistic regression analysis was performed to identify predictors of treatment response and outcomes.

Results
In this study, 40 children with a mean age (3.397 ± 2.192) with lymphadenopathy were investigated.34 (85%) children were below 5 years old, and 6 (15.4%) children were above 5 years old.The sex distribution of the children showed that 28 (70%) were boys, and the rest were girls Table (1).In this study, we examined the factors that can potentially influence the response to antibiotic treatment and the final outcome of the disease using logistic regression analysis, as presented in Table 4.Among these factors, the age of the child was found to have a significant impact.Specifically, as the child's age increases, the positive response to treatment decreases, with an odds ratio (OR) of 0.65 (95% confidence interval (CI): 0.43 -0.99, p = 0.04).Furthermore, observed a positive effect of the duration of limited physical activity (LPA) on treatment response.Increasing the duration of LPA was associated with an increased response to treatment, with an odds ratio (OR) of 1.22 (95% confidence interval (CI): 1.02 -1.53, p = 0.03).
Another influential factor on treatment response was lymphadenopathy size, which had a positive effect with an odds ratio (OR) of 1.25 (95% confidence interval (CI): 1.10-1.60,p = 0.04).Increasing the white blood cell count (WBC) also had a significant impact on treatment and response to treatment, with an odds ratio (OR) of 1.15 (95% confidence interval (CI): 1.05-1.32,p = 0.05).In this study, the only factor that had a significant effect on the disease outcome was erythrocyte sedimentation rate (ESR), where an increase in ESR influenced the final outcome of the disease, with an odds ratio (OR) of 1.13 (95% confidence interval (CI): 1.01-1.25,p = 0.02) Table (4).

Discussion
It is crucial to handle lymphadenopathy in children appropriately as it is a common finding during routine pediatric examinations [15,16].The cause of lymphadenopathy in a child can range from a benign and transient finding, such as lymphadenopathy following upper respiratory infections, to a serious and variable diagnosis of malignancy.Therefore, having sufficient knowledge about proper evaluation and disease management can be highly beneficial [17].It should be noted that, in addition to the fact that most cases of lympadenopathy in children are self-limiting, the more severe cases of the disease should be given more attention.When managing and treating the disease, attention should be paid to taking a thorough history and physical examination, which will enable correct diagnosis and appropriate treatment initiation.Given that in most cases, an antibiotic treatment is used to treat the disease, appropriate treatment algorithms in this regard can be important and necessary [14].
In a study conducted in Canada by Long et al. (2020) with the aim of describing the clinical features and management of acute lymphadenopathy and identifying risk factors for the disease's complications, the medical records of children under 17 years of age with less than 2 weeks of lymphadenopathy were used.Of the 1023 health records, 567 participants with acute lymphadenopathy were analyzed.Most children with acute lymphadenopathy were treated with oral antibiotics.They did not need to be readmitted to the emergency department or undergo surgical drainage, which is in line with the results of the present study [18].
In the present study, the treatment method used was antibiotics (except for chronic and malignancies cases), which showed to be effective in treating lymphadenopathy in children.In In the present study, the most common sites of lymphadenopathy were Posterior cervical and Submental.In the study conducted by Neven et al. (2020), the Submandibular and Posterior cervical were identified as the most important sites of lymphadenopathy [20].In another study conducted, the Submandibular was the most common site [21].In the present study, the most common symptoms in children were Mass, Fever, Rigor, and Weight Loss, while in the study conducted by Kang et al. (2016) in South Korea, the most common symptom was fever [22].
In the evaluation and treatment of the disease, a range of clinical symptoms such as lymph node size, location of the nodes, presence of pain and tenderness in the patients, and adhesion of the lymph nodes should be taken into consideration [5].It should be noted that antibiotic treatment compared to surgical methods significantly reduces the duration of stay of children in the hospital.For this reason, it is recommended that the best treatment method for children is antibiotic treatment [23,24].

Conclusions
The treatment strategy can be different depending on the type of lymphadenopathy.The results of this study showed that in the patients who were treated with antibiotics, the drug was able to lead to some degree of recovery, so it can be used in the treatment and management of children's lymphadenopathy.

Recommendations
Lymphadenopathy is a common finding in clinical practice of physicians.The most serious task is to differentiate benign conditions from malignant disorders which require urgent attention and management.
A good history and thorough physical examination with Judicious use of investigations may avoid unnecessary stress and anxiety for patients and their parents, while expediting diagnosis and therapy where appropriate.
white blood cell count (WBC) measured in x10^10/L, erythrocyte sedimentation rate (ESR) in mm/hour, and C-reactive protein (CRP) levels in mg/dL.Broad spectrum antibiotics have been used ,mainly amoxicillin and clavulanic acid 200mg,400mg and ceftriaxone vial 500mg which found to give the best outcome in the management.
the evidence-based study conducted by Eskander et al. (2022), it was shown that antibiotics can be used in the ORIGINAL RESEARCH Published: 25 December 2023 Doi: 10.26505/DJM.25027640613treatment process.This finding is consistent with the present study because the clinical results of the number of people who were treated with antibiotics were satisfactory and beneficial [19].

Table ( 3
): Treatment method and disease outcome in children

Table ( 4
): Logistic regression model for Response to Antibiotic/ Outcome