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Dr. Ficus, MD
Dr. Ficus, MD, Pediatrician
Category: Pediatrics
Satisfied Customers: 711
Experience:  14 years in private practice in the U.S.
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my son has large lump on right side of his neck,... Dr ordered

Customer Question

my son has large lump on right side of his neck,... Dr ordered CBC and other tests,... CRP, ESR,... and Iron. His white blood cell count was low (?) and his ESR was elevated. Not sure exact numbers. He had Ultrasound done yesterday,.... Right lump is very large,... didn't see measurements,.... but the checked left side,... and the ones on that side were 1.5-2 cm. He is tired all the time,... very pale,... has lost his appetite, still eats but not as much as he used to,... in August he got this really weird rash in his right arm pit,... looked like HIVES,... took 2 weeks to go away,... even with Benadryl,... he's been complaining of headaches which isn't normal for him,... any suggestions,...
Submitted: 1 year ago.
Category: Pediatrics
Expert:  Dr. Ficus, MD replied 1 year ago.

Dr.FicusMD :

I'll do my best to answer your question. If you're available for chat, let's get started.

Dr.FicusMD :

Hi! I'm sorry your child is ill. My first thought would be for mononucleosis, either caused by Epstein Barr Virus or Cytomegalo Virus. Both of these can be investigated by blood tests that look for the IgM antibody to the virus. Typical symptoms of these illnesses are as you describe---big lymph nodes, low white count, high ESR, fatigue

Customer:

his Mono test was neg


 

Customer:

EBV neg too


 

Dr.FicusMD :

Did they do a "mono spot" or actually send an antibody level?


 

Dr.FicusMD :

Ok. Did they look for CMV?


 

Customer:

CMV?


 

Customer:

not sure what that one is?


 

Dr.FicusMD :

Has he had fever? Some kids with cat scratch fever will get a very large cervical lymph node as you describe.

Dr.FicusMD :

CMV = cytomegalo virus. It's another cause of mono-like illness other than EBV.

Dr.FicusMD :

Quite common in children.

Dr.FicusMD :

They

Dr.FicusMD :

can also look at uric acid and lactic acid dehydrogenase (LDH) enzymes as markers for possible cancers. If those are normal then that would be reassuring.

Customer:

they did not test for that


 

Dr.FicusMD :

Ok. So that's one thought--the CMV. They can send an IgM antibody level just like they did for EBV.

Customer:

that's what I was thinking they would test for


 

Dr.FicusMD :

Has he had fever?

Customer:

not recently


 

Dr.FicusMD :

How long as the lump been there?

Customer:

only noticed it a week ago Thursday


 

Customer:

but he's had other symptoms prior


 

Dr.FicusMD :

It's not uncommon for viral illnesses to cause a decrease in the white count and an elevation in the ESR, so that would be my first thought. While cancers like lymphoma and leukemias can cause large lymph nodes and lower white counts they typically also cause decreases in the other cell lines (red blood cells (anemia) and p

Dr.FicusMD :

platelets).


 

Customer:

fatigue, paleness, the weird rash on same side,... lack of appetite


 

Dr.FicusMD :

Another thought would be for tick borne illnesses like Ehrlichia or Lyme. Those could also cause the symptoms you're seeing and the labs results you've received. Did he have a tick bite this summer that you are aware of?

Customer:

headaches, jaw pain, had a little cough in Sept and said it really hurt his chest to cough, and now the big lump in neck,... his left side has bigger ones I wasn't aware of until yesterdays Ultrasound,...


 

Customer:

no ticks where we live


 

Dr.FicusMD :

Might also be worth looking at liver enzymes as illnesses like CMV will sometimes cause a temporary hepatitis and cause elevation in those numbers. Has he had a chest xray?

Customer:

no chest x-ray yet


 

Dr.FicusMD :

(I should move to Canada---hate ticks)

Customer:

lol


 

Customer:

he did have a case of pin worms in the summer


 

Dr.FicusMD :

Ok. It sounds like he has had symptoms of one sort or another for several weeks. I would like to see another CBC and see which way the counts are going. It would also be helpful to ck the ESR again and see if its going up or down (ESR is a very non-specific marker for inflammation in the body. If it's going up there's an ongoing process that's making the body upset).

Dr.FicusMD :

Shouldn't be the pin worms.

Customer:

they ordered Mumps test too,... results for that next week,...


 

Customer:

more blood work Nov 9,... if not sooner


 

Customer:

what is the normal size for the lymph nodes?


 

Dr.FicusMD :

It would be reasonable to get a chest Xray as Hodgkins lymphoma will present with these symptoms and a chest mass that is usually seen on xray. Nov 9 is too far away. I'd want to see another set of labs within 1 week of the last ones. And the CMV antibody level.

Dr.FicusMD :

Lymph nodes in kids can pop up on and off but are usually pea-sized, firm, and mobile under the skin. These nodes sound large, which suggests infection or illness of some kind.

Customer:

CMV is the cat scratch?


 

Customer:

does that actually come from a cat scratch?


 

Dr.FicusMD :

CMV is cytomegalo virus. It's quite common in children.

Customer:

what is the treatment for CMV?


 

Dr.FicusMD :

Cat scratch is Bartonella hensleae. Hard to treat without actually removing the nodes surgically but not terribly dangerous.

Dr.FicusMD :

No treatment for CMV. It will go away over the course of several weeks.

Dr.FicusMD :

Might be worth getting a chest or abdominal CT scan to look for other nodes if the labs are still abnormal and the chest xray doesn't provide any clues.

Dr.FicusMD :

I, like you, am concerned (but not panicked). He warrants further evaluation and that should be within 1-2 weeks, not in a month.

Customer:

The radiologist isn't aware that we had blood work already and said the Dr would want to monitor him closely based on the ultrasound results,... :(


 

Dr.FicusMD :

Did he say anything specific about the ultrasound?

Customer:

so I am concerned,... My Dr here is very lacksy daisy about it,... wants to wait and see,.... friends of mine have a little boy who's dr's wanted to wait and see for 2 months,... and he was nearly in cardiac failure because of leukemia,... I won't let that happen to my child!


 

Customer:

The Radiologist can't say anything specific,... has to come from your own Dr,... they will forward the results!


 

Dr.FicusMD :

It's certainly reasonable to have him evaluated by a pediatrician at children's hospital. Likely they have a general pediatrics clinic that can evaluate him. An oncologist isn't necessary yet without repeating the labs. BUT I don't like the "wait and see" approach. I absolutely agree with you. You are your child's best advocate and have to do what your gut tells you is in his best interest. If he were my patient I would want to see the labs repeated within a week and if they weren't reassuring me that the issue was improving I would want an oncologist or infectious disease specialist to see him.

Customer:

we will find out more later this week!


 

Customer:

ok,.. so it's not just me being a paranoid mom!


 

Dr.FicusMD :

Ok. I hope you get the answers you need soon. Ask for CMV testing, consider the cat scratch (bartonella) and at a minimum get the labs you've had repeated in about 1 week.

Customer:

his labs were done last week Tuesday


 

Customer:

on the 9th


 

Dr.FicusMD :

No, absolutely not paranoid. I'm concerned, too, and you need to get to the bottom of it. If it's viral you may never really know the cause but it should show you some improvement on its own within a couple of weeks.

Dr.FicusMD :

Ok, and they want to wait a MONTH to repeat them. No. I'm not ok with that.

Dr.FicusMD :

If y

Dr.FicusMD :

your primary doc won't follow it up sooner I'd find someone else to see him.

Customer:

that's what the parents of the little boy with leukemia said too


 

Dr.FicusMD :

Absolutely.

Customer:

I think I may ask to be referred to a CHildrens Hospital just for peace of mind


 

Customer:

Thank you so much for answering my questions


 

Customer:

I feel like my Dr is kinda brushing me off,.... yet just trying to reassure me that it's nothing


 

Dr.FicusMD :

I think that's reasonable. You might just want to start with general pediatrics there as, if it's not an oncology problem you'll be told it's not their disease and be left without answers again. Start with the generalists and they should be able to help drill down and point you in the right direction.

Customer:

a pediatrician?


 

Dr.FicusMD :

My pleasure to assist. Mom's have that 6th sense and I always listen to it. You know when there's something that's not right with your child.

Customer:

you know how long it takes to get in to one of them in my community? FOREVER!


 

Customer:

I knew back in SEPT


 

Customer:

it's just showing itself now!


 

Dr.FicusMD :

Yes, a general pediatrician is who I would see first at Children's. They should have a department of general pediatrics that has a clinic where you can have him seen. I understand the Canadian system isn't known for speed.

Dr.FicusMD :

Bring him to Tennessee. I'll see him Monday :o)

Customer:

what do you think the hive like rash could've been in his armpit?


 

Dr.FicusMD :

Not sure about that. Usually rashes are more generalized when they are from viral illnesses. It might be totally unrelated.

Dr.FicusMD :

If you lived here I'd think about ticks but I guess that's not a concern.

Customer:

lol I'll be on the next flight! I just drove 12 hrs for him to have an Ultrasound! on roads that were SHEER ICE!


 

Dr.FicusMD :

Oh MY GOODNESS! It's 77 degrees here today. I'll take the sunny south!

Customer:

so slick I stopped at a traffic accident and slid off the road myself because of the angle of the road! It was AWFUL!!!


 

Dr.FicusMD :

And with a sick child who you're worried about. How awful!

Customer:

4 kids under 8 in the truck!


 

Dr.FicusMD :

Well, I hope you get some help soon. I hate hearing about stories like this when I can't do much to help.

Customer:

it was an AMAZINGLY terrifying trip I tell you!


 

Dr.FicusMD :

Sounds like it!

Customer:

We did just get home 2 hrs ago,... time to get them all into bed! Thank you again for the advice,... I wrote down those tests, and will ask the Dr about them at our next appointment which I will make for early in the week!


 

Customer:

Then I will have results back within 2 days


 

Dr.FicusMD :

Ok. If you get lab results and want to run them by me you can always reply to this thread again and I'll get an email that you need me. I'd be happy to look at the numbers and any other info you get. Keep me posted.

Dr.FicusMD :

If I've been helpful kindly leave positive feedback prior to leaving the site. You can always come back to this thread to get me again.

Customer:

Thank you so much,.... How will I find this thread again?


 

Dr.FicusMD :

I'm on-line nearly every evening (It's 10:30pm central time). If you go into your original post you can just reply again as you are doing now. If you can't find it then put in a request for me and I'll get an email and know to get back with you.

Customer:

Ok,... I'll see If I can save this!


 

Customer:

I'll keep you posted!


 

Dr.FicusMD :

Ok. Get some rest and keep me posted.

Dr. Ficus, MD, Pediatrician
Category: Pediatrics
Satisfied Customers: 711
Experience: 14 years in private practice in the U.S.
Dr. Ficus, MD and other Pediatrics Specialists are ready to help you
Expert:  Dr. Ficus, MD replied 1 year ago.
Thank you for the positive rating! I'm sending this so that you'll have an e-mail in your files that you can reply to when you're ready. Hopefully that will make things easier if you decide you need to chat again.
Customer: replied 1 year ago.

Hello Dr.Ficus,... we had our follow up appointment today,... Dr refused to repeat the blood work as he's referring my son to a Pediatrician and said she will request the tests she wants done. I DID get a print out of his previous results,... his WBC was 4.9, his CRP was 1.5 and his ESR was 15 and his PLT was 274. The radiologist report for his Ultrasound measured the largest lump on the right at 14x11x7 and the largest on the left at 14x15x8.


 

Expert:  Dr. Ficus, MD replied 1 year ago.
Hi Bambi! It's Dr. Ficus. I was just checking to see if you got any new information about your son and if you'd like my assistance. Reply when it's convenient for you to do so.
Customer: replied 1 year ago.

Hello Dr.Ficus,... we had our follow up appointment today,... Dr refused to repeat the blood work as he's referring my son to a Pediatrician and said she will request the tests she wants done. I DID get a print out of his previous results,... his WBC was 4.9, his CRP was 1.5 and his ESR was 15 and his PLT was 274. The radiologist report for his Ultrasound measured the largest lump on the right at 14x11x7 and the largest on the left at 14x15x8.

Expert:  Dr. Ficus, MD replied 1 year ago.
His blood work wasn't too terribly worrisome by itself, but those nodes are quite large. I'm glad you're being referred on but hope it won't be a long wait to see that pediatrician. Keep me posted.
Customer: replied 1 year ago.

Hello,... I realize I never updated you on my sons condition. We were sent to a pediatrician at a Children's Hospital, where they determined my son was suffering from Post Infectious Fatigue Syndrome, cause by EBV. We did not find this out until Jan 2013! Many months of wondering,... he was put on limited physical activity and rest as needed,... no contact sports,... and now is right as rain! He's almost back to his old self! They said it could take up to 2 yrs, from on set of symptoms,... and has been just over 12 months!

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