Method for differential diagnostics of lymphadenopathies of different genesis in children

FIELD: medicine, oncology.

SUBSTANCE: in plasma of peripheral blood in children one should detect cathepsin D activity and antiproteolytic activity and calculate coefficient of their ratio. At obtaining the value of coefficient being equal 10.5 ± 2 one should detect lymphadenopathy of benign genesis in a child to choose a waiting-type tactics at prescribing antiphlogistic therapy. At coefficient value ranged 30-100 on should detect malignant lymphoproliferative process in a child to immediately fulfill an excision biopsy of a lymph node along histological studying and at proving the diagnosis special therapy should be indicated. Application of the present method enables to conduct additional objective differential-diagnostic test under disputable cases at the stage being before carrying out histological analysis of lymph nodes and prescribe necessary therapy for every concrete case in due time.

EFFECT: higher accuracy of differential diagnostics.

3 ex, 1 tbl

 

The invention relates to medicine, specifically to Oncology, and can be used for planning treatment and diagnostic tactics in children with benign and malignant lymphoproliferative diseases.

In domestic and foreign literature is constantly discussed the issue of lymphadenopathy in children and suggested about specific difficulties of differential diagnosis of Hodgkin's disease and malignant lymphomas with other diseases accompanied by enlarged lymph nodes. In practice the differential diagnosis of lymphoproliferative disorders often have to deal with three kinds of lymphadenopathy:

- nonspecific lymphadenopathy, the cause of which is not installed (usually of viral origin);

- reactive hyperplasia of lymph nodes;

- lymphadenopathy malignant nature.

There is a method for differential diagnosis of malignant lymphoma (Durnev L.A., Ermakov Y.S., Sementsova C.V. Malignant lymphoma in children., Moscow. Medicine, 1979. - 214 S.), in which the authors note that many infectious diseases of childhood are accompanied by lymphadenitis. Against this background, the attention of clinicians easily slips into the lymph nodes - the first local manifestation of systemic op the Holevo disease: Hodgkin's lymphoma or lymphosarcoma. In outpatient practice with long-term recurrent lymphadenitis apply heat physiotherapeutic procedures, contributing to the progression of the pathological process in the case of a malignant nature, and antibiotics with partial (temporary) effect or no effect. And only then perform cytological, and when the uncertainty of its results histological examination of peripheral lymph nodes, which is the only reliable method for diagnosing malignant lesions of the lymphatic system.

The authors indicate that in the current diagnostic scheme it is impossible to do without cytochemical studies, as they greatly complement and clarify histo - cytological study. For the differential diagnosis of importance in some cases, the performance of diagnostic laparotomy with biopsy of intra-abdominal and retroperitoneal lymph nodes, in the absence of those on the periphery. With the rapid generalization of the malignant process in children and the need to maximize the early use of chemotherapy in combination with other therapeutic interventions diagnostic laparotomy in children is low and holding it at the present time unnecessarily.

A known method of differential diagnosis of Hodgkin's disease in children (Colige the B.A. Hodgkin's disease in children. - Leningrad. Medicine, 1990. - 206 S.), involving three main points:

- differential diagnosis, i.e. the distinguishing this disease from other, similar clinical picture; as with chlamydia leading clinical symptom is enlargement of peripheral lymph nodes, in practice they should be differentiated from various lymphadenopathy, which are very numerous and diverse in children;

- confirmation of the diagnosis is suspected on clinical grounds. Currently, the only (or rather, absolute proof of the presence in a patient with malignant process is histological examination of the affected tissue (often remote biopsy of the lymph node); only in rare cases, the final diagnosis is established on the basis of cytological research, we are talking about clinical situations where it is not possible to perform a biopsy and get the material for histological examination;

to identify the prevalence of process in the body, i.e. determining the stage of the disease.

For the early detection of malignant process in children, the authors consider necessary in unclear cases to recommend puncture limfaticeskih the node with subsequent Cytology material. If you suspect a Hodgkin's disease patient should be referred to the hospital for the biopsy of the lymph node.

However, there are certain difficulties in the detection of Hodgkin's disease in children, while major errors occur when the differential diagnosis with lymphadenitis and lymphoid hyperplasia. In some cases insufficiently expressed pathological changes in the lymph node does not allow and morphologist confident to speak out in favor of chlamydia. With this situation, the authors have encountered in 7% of cases, even if the examination of the biopsy material was expressed about the presence of prostatic tissue of the lymph node. The purpose in such cases, thermal and physical therapy may cause harm to the patient, as well as the diagnostic delay period longer than one month.

In the course of treatment should be focused on the knowledge and experience of a specific doctor, and not on objective indicators of the child's body, accompanying benign or malignant lymphoproliferative diseases.

Thus, it is obvious that there is no objective criterion that can be used as an additional differential diagnostic test in doubtful clinical cases at the stage preceding the histological analysis udalen the x lymph nodes, it also allows to determine whether a delay, or Vice versa, reducing the time to biopsy a lymph node.

The aim of the invention is the definition of objective criteria for differential diagnostic measures and treatment of children with lymphoproliferative processes.

This objective is achieved in that in the peripheral plasma of children determine the activity of cathepsin D and antiproteolytic activity, calculate the coefficient of correlation, coefficient, equal to 10.5±2, clinically establish the child benign lymphadenopathy Genesis, choose wait-and-see tactics with the appointment of anti-inflammatory therapy. When the magnitude of the coefficient of 30 to 100 clinically establish the child's malignant lymphoproliferative process, immediately produce an excisional biopsy of the lymph node with histological examination and confirmation of diagnosis appoint special treatment.

The method of differential diagnosis of lymphadenopathy different Genesis in children is new, as it is unknown the level of medicine in the application of diagnostic and therapeutic tactics in children with benign and malignant lymphoproliferative diseases.

The novelty of the invention lies in the fact that PLA is IU the peripheral blood of children in the survey process to determine the activity of cathepsin D and inhibitors of proteases, calculate the coefficient of correlation and for values equal to 10.5±2, clinically establish the child benign lymphadenopathy Genesis and choose the appropriate tactics of the patient, and when the magnitude of the coefficient of 30 to 100 clinically establish the child's malignant lymphoproliferative process and appoint adequate diagnostic and treatment center.

In the available sources of information Russia, CIS and abroad indications for a similar method of differential diagnosis we have not identified.

The invention is industrially applicable as it can be reproduced and repeated many times in the specialized medical health care institutions.

Were examined in 70 children (26 girls and 44 boys) aged 6-11 years with lymphadenopathy of various origins. All children was performed excisional lymph node biopsy followed by histological analysis of lymph node tissue. 25 children was verified benign lymphadenopathy Genesis (PAWS), 25 patients were histologically diagnosed with chlamydia (LGM) and 20 patients - non-Hodgkin lymphoma (NHL). In parallel in the tissue of the lymph node and blood serum was carried out the study of the activity of cathepsin D and inhibitors of proteases with a calculation of the ratio of their activity. Result is you are benchmarking in tissue and serum are presented in the table.

The ratio of the activity of cathepsin D and inhibitors of proteases in tissue lymph nodes and peripheral plasma of children with lymphoproliferative processes
The studied parametersBenign lymphadenopathy (PAWS)Chlamydia (LGM)Non-Hodgkin lymphoma (NHL)
Coeff. cat. D/inhibitor in the tissue of the lymph node95,7±8,6233,8±21,71714,7±61,31
Coeff. cat. D/inhibitor in plasma10,3±0,937,0±3,2177,9±6,31
Note: 1 - significantly compared to the values at PAWS (p<0,05).

We have compared the results of the study hydrolytic system in the tissue of the lymph nodes in the studied lymphoproliferative processes and plasma of these patients. It turned out that the value of the coefficient CATD/inhibitor in peripheral plasma of children fully reflect such values in the tissue of the lymph nodes with rank correlation coefficient of 0.9. The study has been the basis for the use of the coefficient value of cathepsin D/inhibitor in plasma of children as the object of the main test for the auxiliary differential diagnosis of lymphoproliferative disorders.

The method is as follows.

The child take 1 ml of peripheral blood in a test tube containing 0.1 ml of sodium citrate, centrifuged 15 min at 3000 rpm, selected blood plasma and determine in it the activity of cathepsin D and inhibitors of proteases with further calculation of their correlation coefficient.

1. The process of determining the activity of cathepsin D: the experimental sample contribute 0.3 ml amino-acetate buffer pH of 2.2, 0.4 ml of the diluted hemoglobin and 0.1 ml of blood plasma. Samples incubated while stirring at room temperature for 30 minutes Then add 0.8 ml 0,3N trichloroacetic acid (THU). Centrifuged 30 min at 3000 rpm Select 0.5 ml of centrifugate, add 1 ml of 4% NaOH and 0.5 ml of diluted 3 times with reagent Polina. Leave to stand in the dark for 15 min and spectrophotometery at a wavelength of 680 nm. As a control using a sample in which THU added prior to incubation (Ogloblin OG, Rouanet CENTURIES, O. Kazakova, Pashina T.S. Inhibition kininogenase activity of cathepsins D cyclotosaurus inhibitor from rabbit serum. // Biochemistry. - 1981. - 46. - 4. - S-673).

2. The course of determination of protease inhibitor: in the experimental sample contribute 0.2 ml diluted 100-fold in blood plasma, add 0.2 ml of 0.015% trypsin, incubated 15 min at room temperature, then add 0.6 ml of Tris-HCl buffer pH 7.6 and 1 ml of 1% casein. Incubated sample 20 is in at 37° With and add 3 ml of 5% THU. Centrifuged 30 min at 3000 rpm Spectrophotometery at a wavelength of 280 nm. As a control using a sample in which THU added prior to incubation (Veremeenko PHD, Goloborodko A.I., Kizim A.I. Proteolysis in normal and pathological conditions. // Kiev "Health". 1988. S-174, 176).

Determining the level of activity of cathepsin D and inhibitors of proteases expect their relationship.

Upon receipt of the ratio, equal to 10.5±2,0, clinically established that a child benign lymphadenopathy Genesis, and the value of 30-100, - malignant lymphoproliferative diseases.

The effectiveness of the proposed method was equal to 95.7%. A specific example of the method can serve as a statement of medical history:

Clinical example No. 1.

Patient T., age 10, case history No. 6740/R, was admitted to the pediatric Oncology Department 24.04.03, with a presumptive diagnosis of systemic disease.

Complaints at admission for the presence of tumor formation in the neck to the right, loss of appetite, weakness.

From the anamnesis of the disease it is known that the child is sick 1 month ago, when amid SARS appeared tumorous formation on the lateral surface of the neck to the right, painless, diameter 2 cm, the temperature rose to 37.5°addressed to the doctor in the LM is Elista, treatment: ampicillin 500 thousand × 2 times a day, b/m, 10 days. After treatment decreased temperature, but education on the neck right not decreased assigned thermal treatments No. 10, without effect.

In the last 7 days education has increased in size up to 2.5 cm in diameter, decreased appetite, weakness, the child is sent to RNII.

When applying the General condition is satisfactory.

A proper physique, reduced power state. In the mind, adequately responds to the surrounding. Nasal breathing is free. Peripheral lymph nodes: on the side of the neck to the right palpable enlarged lymph nodes up to 2 cm in diameter, densely-elastic consistence, sedentary, the skin over them is not changed, the left - lymph nodes are "chain" is from 0.5 to 0.9 cm, other groups of lymph nodes, available palpation, not increased. Pale skin, clean. Zev calm. In the lungs vesicular breathing, wheezing no. Heart sounds are clear, rhythmic. The abdomen is soft, painless. Liver at the edge of the costal arch, spleen not palpated.

Patients received complex diagnostic procedures:

the CBC 22.04.03,: hemoglobin - 128 g/l, erythrocytes - 4,3×1012/l CPU-0.89, leukocyte - 4,2×109/l, ESR - 14 mm/h, stab - 2, segmentate the nye - 31, eosinophils, 4 - basophils - 0, monocytes - 3, lymphocyte - 60;

biochemical study of blood on cathepsin D and antiproteolytic activity 22.04.03 g - ratio is 10.5;

Ultrasound of the neck and supraclavicular lymph nodes from two sides 21.04.03, No. 5867 - side surface to the right enlarged lymph nodes 1,2-1,7 cm in diameter, from left to 0.9, see

Ultrasound of abdomen and retroperitoneum 21.04.03, No. 5867 - symptoms of abdominal cavity and retroperitoneal space is not detected;

Chest x-ray of the chest 21.04.03 g, No. 15: in the lungs without focal and infiltrative changes. The roots are differentiated. The mediastinum is not extended. Heart, aorta without pathology.

Needle biopsy of the cervical lymph node on the right 18.04.03, blood, accumulation of lymphoid elements with signs of atypia in individual cells;

24.04.03, - excisional biopsy of the cervical lymph node on the right, the histological conclusion No. 690166 - chronic lymphadenitis. On the basis of a comprehensive survey has a diagnosis of subacute, simple, cervical lymphadenitis right.

ELISA for chlamydia 12.05.03, - Ig M 1/240;

Treatment: macropen 400×2 times a day, aevit 1 pills × 2 times a day, Vit. With 1 pills × 3 times a day for 10 days.

After treatment, marked regression of peripheral lymph nodes, appetite.

Baby wile the Yong, is under medical supervision without evidence of disease for 10 months.

Clinical example No. 2.

Patient D., aged 11, case history No. 11038/0, was admitted to the pediatric Oncology Department 17.07.02 years with a diagnosis of cervical lymphadenopathy. Complaints for admission to nasal breathing, periodic temperature increase to 37.2°C, enlarged lymph nodes in the area of the lateral surface of the left side of the neck, pain in this area, and headaches.

From the anamnesis of the disease it is known that the child is acutely ill, 10 days ago, when after hypothermia appeared nasal congestion, increased body temperature, increased and became painful lymph nodes in the neck on the left.

When applying the General condition of the girls are satisfactory.

A proper physique, increased power state. In the mind, adequately responds to the surrounding. Nasal breathing is difficult, no detachable. Peripheral lymph nodes: on the lateral surface of the left side of the neck is palpated enlarged lymph node up to 2.5 cm in diameter, densely-elastic consistence, sedentary, the skin over them is not changed, the right a single to 0.5, see Other groups of lymph nodes are available palpation is not increased. Skin and visible mucous membranes normal paint, no rash. Zev: hypertrophy m is Nalin, plaque no. In the lungs vesicular breathing, wheezing no. Heart sounds are clear, rhythmic. The abdomen is soft, painless. Liver at the edge of the costal arch, spleen not palpated.

Patients received complex diagnostic procedures:

the CBC 18.07.02,: hemoglobin - 110 g/l, erythrocytes - 4,0×1012/l CPU-0,82, platelet - 216,6×109/l, leucocytes - 8,0×109/l, ESR - 23 mm/h, stab - 8, segmented - 62, eosinophils - 0, basophils - 0, monocytes - 7, lymphocytes - 23;

biochemical study of blood on cathepsin D and antiproteolytic activity 18.07.02 g - ratio is 39.2;

Ultrasound of the neck and supraclavicular lymph nodes from two sides 18.07.02, No. 2928 - side surface of the neck left many lymph nodes of 0.7-2.0 cm, rounded, blood flow is not registered, the right to 0.3-0.5 cm

Ultrasound of abdomen and retroperitoneum 18.07.02, No. 2928 - symptoms of abdominal cavity and retroperitoneal space was not detected.

Radiograph of the chest in frontal and lateral projection (left side) 19.07.02, - pathological changes in the lungs and the mediastinum was not detected;

19.07.02, biopsy of the cervical lymph node on the left, the histological conclusion No. 656327 - Hodgkin's lymphoma, mixed-cell variant;

On the basis of a comprehensive survey has a diagnosis of Hodgkin's disease stage IA, with lesions of the cervical lymph nodes on the left, CL gr.

Related: Neurocirculatory dystonia, adenoids II degree.

Treatment: 4 course chemotherapy under the scheme VBVP, with an interval of 2 weeks.

With 25.07.02, 1.08.02, 1 course of chemotherapy in/in: vinblastine and 9 mg in the 1st and 8th days; Vepesid 150 mg 1 to 5 days, bleomycin 15 mg in 1 day, per os: prednisone 60 mg from 1 to 8 days.

With 14.08.02, 21.08.02, 2 course of polychemotherapy according to the same scheme.

With 9.09.02, 18.09.02 g 3 course of polychemotherapy according to the same scheme.

With 3.10.02, 10.10.02, 4 course of polychemotherapy according to the same scheme.

Radiation therapy: from 28.10.02, 15.11.02, DHT on the left cervical region, GENUS-2G, SOD-28G.

After treatment the patient is under observation in 3 CL gr. (in remission for 18 months with no signs of recurrence of the disease.

Clinical example No. 3.

Patient M., age 4, case history No. 522/R, was admitted to the pediatric Oncology Department 13.01.03, with a diagnosis of cervical lymphadenopathy, systemic disease (?).

Complaints for admission to nasal breathing, the presence of granulomas education in the neck from both sides, the pain in this area.

From the anamnesis of the disease it is known that the child is sick 1 month ago, when increased body temperature up to 38,2°, sore throat, increased lymph nodes in the neck on both sides, turning to the doctor on a residence, set the Yong diagnosed with lacunar angina assigned to antibiotic treatment for 10 days. After the treatment was normalized temperature slightly decreased in size lymph nodes in the neck from both sides, the child is sent to RNII for further evaluation.

When applying the General condition is satisfactory.

A proper physique, satisfactory nutritional status. In the mind, adequately responds to the surrounding. Nasal breathing is difficult, no detachable. Peripheral lymph nodes: on the side of the neck with two sides palpable enlarged lymph nodes up to 2 cm in diameter, densely-elastic consistence, sedentary, the skin over them is not changed, other groups of lymph nodes, available palpation, not increased. Pale skin, clean. Zev hyperemia, plaque no. In the lungs vesicular breathing, wheezing no. Heart sounds are clear, rhythmic. The abdomen is soft, painless. Liver at the edge of the costal arch, spleen not palpated.

Patients received complex diagnostic procedures:

the CBC 14.01.03,: hemoglobin - 110 g/l, erythrocytes - 3,9×109/l CPU-0,85, leukocytes - 4,3×109/l, ESR-20 mm/h, stab - 5, segmented - 50, eosinophils - 2, basophils, monocytes - 9, lymphocytes - 30;

biochemical study of blood on cathepsin D and antiproteolytic aktivnosti 14.01.03 g - the ratio is 72,5;

Ultrasound of the neck and supraclavicular lymph nodes from two sides 15.01.03,, - on the side of the neck with the two sides of the enlarged lymph nodes up to 2.2 cm in diameter.

Ultrasound of abdomen and retroperitoneum 15.01.03,, - symptoms of abdominal cavity and retroperitoneal space is not detected;

21.01.03, - excisional biopsy of the cervical lymph node on the right, the histological conclusion No. 52-55 Burkitt's lymphoma.

On the basis of a comprehensive survey has a diagnosis of non-Hodgkin b-cell lymphoma II AA stage, with lesions of the cervical-supraclavicular lymph nodes on both sides, CL gr. For further treatment, the child was transferred to the regional hospital where the treatment Protocol BFM-90.

Currently, the child is in remission for 8 months, with no signs of recurrence.

Thus, the data presented clinical observations illustrate the differential diagnostic value of determination of the ratio of the activity of cathepsin D and inhibitors of proteases in peripheral plasma during the examination of children.

Technical and economic efficiency of the claimed method of differential diagnostics of lymphadenopathy different Genesis in children allows

- conduct additional objective differential diagnostic test in controversial clinical SL is the teas on stage, preceding the histological analysis of lymph nodes;

to determine whether a delay, or Vice versa, reducing the time to excisional biopsy of the lymph node;

- timely and appropriate in each case, therapy;

The method of differential diagnosis of lymphadenopathy different Genesis in children, including histology, wherein before carrying out histological studies in peripheral plasma of children determine the activity of cathepsin D and antiproteolytic activity, calculate the coefficient of correlation, coefficient, equal to 10.5±2, clinically establish the child benign lymphadenopathy Genesis, choose wait-and-see tactics with the appointment of anti-inflammatory therapy, when the magnitude of the coefficient of 30 to 100 determine the child's malignant lymphoproliferative process, immediately produce an excisional biopsy of the lymph node with histological examination and confirmation of diagnosis appoint a special treat.



 

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20 cl, 2 dwg

FIELD: ophthalmology.

SUBSTANCE: blood serum hyaluronic acid level is first determined and, when it is below 10 μg/ml by the 50th day of disease, prediction of clinical course of Chlamidia conjunctivitis is regarded as favorable. When indicated characteristic is above 10 μg/ml, unfavorable course of disease is predicted.

EFFECT: increased prediction accuracy.

2 ex

FIELD: narcology and cardiology.

SUBSTANCE: patient undergoes echo-cardiographic examination supplemented by determination of components of LPO/antioxidant system from formula: K/TBA/DD, where K is erythrocyte catalase level, TBA level of TBA-positive products in blood serum; and DD factor characterizing presence or absence of diastolic dysfunction. When this factor is inferior to 2.1, alcohol-induced heart injury is diagnosed.

EFFECT: enabled diagnostics of alcohol-induced heart injury required urgent drug therapy taking into account risk of development of fatal ventricular arrhythmias.

1 tbl

FIELD: veterinary medicine.

SUBSTANCE: method involves testing cattle for infection, determining leukocyte quantity in 1 mcl of blood and comparing to physiologic reference value. Leukocytic formula is derived when detecting incubation stage with segmented neutrophil percentage being determined. Its level being lower than 20% and more, unfavorable leucosis clinical course prognosis is produced.

EFFECT: simplified and accurate prognosis method.

3 tbl

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