Chapter 93 Lumps and Bumps (Case 50)
Patient Care
Clinical Thinking
• What are the patient’s vital signs? Is there any indication of systemic involvement or patient distress?
• If the lesions are on the body, look for signs of infection, inflammation, or redness with surrounding cellulitis.
Physical Examination
• Determine how deep in the skin this lesion occurs and its size. If it is a cutaneous lesion, the skin does not move over the surface and puckers when the adjacent skin and tissue are compressed and elevated.
• If the bump is palpated over the underlying fascia, it is in the subcutaneous tissue and is essentially benign. However, if the lesion is fixed to the underlying fascia, or the examiner cannot be sure, then the possibility of malignancy should be considered.
• Examine the lesion for signs of infection—tenderness on palpation, redness or cellulitis of the surrounding skin; note if the central area is fluctuant, as in an abscess.
Tests for Consideration
• Complete blood count (CBC) An elevated white blood cell count can strengthen your diagnosis of an infectious process. A low platelet count is consistent with the diagnosis of petechiae. $35
• Erythrocyte sedimentation rate (ESR): If considering an underlying systemic inflammatory process, either ESR or CRP (or both) is often elevated $25
• Blood culture: Cultures identify specific bacterial etiologies and may allow narrowing of your antibiotic therapy $100
• Test for mononucleosis and streptococci: When appropriate to evaluate cervical lymphadenopathy $45
• Aspiration of the node for culture and sensitivity: May be required to define the process as specific and guide appropriate antibiotic therapy $100-$1000
Clinical Entities: Medical Knowledge
| Warts | |
|---|---|
| Pϕ | Warts are viral-induced intraepidermal tumors caused by human papillomavirus. Spontaneous resolution occurs in 9 to 24 months. They may be characterized on the basis of their appearance (flat, plantar, venereal). |
| TP | Most are skin colored, sharply demarcated papules that have a firm and rough surface. They are often asymptomatic, although on pressure-bearing surfaces they may be painful. |
| Dx | Diagnosis is made by visual inspection. |
| Tx | Cryotherapy—using a cotton swab dipped in liquid nitrogen, applied to the center of the wart for 20 to 30 seconds. Other topical therapies exist but require several weeks of therapy. These include salicylic acid paint (10%); salicylic acid plaster (40%); cantharidin applications; and podophyllin (25%) used for venereal warts. Most of these treatments are applied by specialty physicians. See Nelson Essentials 98. |
| Molluscum Contagiosum | |
|---|---|
| Pϕ | Molluscum contagiosum is a white or whitish-yellow papule with central umbilication caused by a poxvirus. |
| TP | The papules tend to be clustered, occurring anywhere on the skin surface. They may be in the genital area of adults as a sexually transmitted disease. |
| Dx | Diagnosis is made by visual inspection, as described above. In addition, Wright stain of the contents reveals epidermal cytoplasmic viral inclusions. |
| Tx | Sharp dermal curettage is the treatment of choice. Spontaneous resolution occurs in 2 to 3 years. See Nelson Essentials 98. |
| Abscess/Furuncle | |
|---|---|
| Pϕ | A furuncle is a deep lesion of bacterial folliculitis usually caused by staphylococcus or streptococcus. |
| TP | A painful, erythematous, indurated nodule may be single or occur in crops. It is often associated with a surrounding red flare. As the lesion matures, a central pustule develops and ruptures with drainage of contents. |
| Dx | Diagnosis is made by visual inspection. |
| Tx | First-line therapy for early nonfluctuant lesions is an oral antistaphyloccocal drug that also covers methicillin-resistant staphylococcus. (clindamycin or trimethoprim/sulfamethoxazole plus rifampin). See Nelson Essentials 98. |
| Nevus | |
|---|---|
| Pϕ | A nevus is a benign hamartoma of melanocytes. Nevi are extremely common. A congenital nevus has an increased risk for malignant transformation into malignant melanoma, although this transformation is rare during childhood. Dysplastic nevi develop in the second decade of life, have haphazard coloration, and are larger than 7 mm with poorly demarcated borders. Their morphologic appearance is intermediate between malignant melanoma and benign nevi. |
| TP | A benign nevus is an evenly pigmented brown lesion. |
| Dx | Referral to dermatology may be indicated with biopsy for histologic study in certain cases. |
| Tx | Refer to a specialist for treatment. A nevus may require surgical excision. See Nelson Essentials 193. |
| Insect Bites | |
|---|---|
| Pϕ | Insect bites may develop into a red papule or occasionally a vesicle at the site in persons who are sensitive. Most often the insects responsible are fleas, mosquitoes, and ants. |
| TP | Typical presentation is as stated above. Insect bites often occur on extremities. |
| Dx | Diagnosis is made by visual inspection. |
| Tx | Treatment includes patient education, personal insect repellant, and, for mild disease, corticosteroid creams. See Nelson Essentials 195. |
| Sebaceous Cysts | |
|---|---|
| Pϕ | Sebaceous cysts are formed from hair follicles that become blocked by a keratin plug or inflammation in a superficial scar over the surface. As epithelium continues to turn over, desquamated stratum corneum remains trapped in the follicle and keratin distends the follicle, forming the cyst. |
| TP | They may occur anywhere on the body where hair is located. The borders are smooth and well demarcated. They are concerning if located on the face, for cosmetic reasons, or if irritated by pressure, in which case they become inflamed. |
| Dx | Diagnosis is made by visual inspection and palpation. |
| Tx | Treatment is generally unnecessary. However, excision may be required for cosmetic or symptomatic lesions. When infected, cysts should be drained, irrigated, and allowed to heal by secondary intention. See Nelson Essentials 188. |
| Hemangioma | |
|---|---|
| Pϕ | Hemangioma, if capillary (strawberry birthmark), is a benign tumor of dilated blood vessels. It is the most common tumor of infancy. |
| TP | Generally, hemangiomas grow from birth to 6 months of age. Growth can happen very quickly. Involution of the lesion begins at 6 to 18 months, but lesions can last up to 5 years. Over time, the color changes from strawberry red to a more violaceous hue. |
| Dx | Diagnosis is made by visual inspection. |
| Tx | Treatment includes parental counseling. However, if the hemangioma occurs in an area causing organ compromise (e.g., airway obstruction, compromised vision), other therapies may be required. These include excision, radiation, embolization, and laser therapy. See Nelson Essentials 194. |
| Lipoma | |
|---|---|
| Pϕ | Lipoma is a very common hamartoma of fatty tissue. |
| TP | Lipomas may occur anywhere on the body. The tumor has a characteristic soft appropriate texture with discrete borders. Lipomas are sometimes sensitive to pressure. Paraspinal lipomas may protrude deeply between the transverse spinous processes and encroach on spinal nerve foramina. |
| Dx | Diagnosis is made by clinical examination. Magnetic resonance imaging may be if the lesion is noted to be midline over the spine and needs to be differentiated from other conditions. |
| Tx | Excision is required if diagnosis is in doubt or if symptomatic. See Nelson Essentials 126. |
| Pyogenic Granuloma | |
|---|---|
| Pϕ | Pyogenic granuloma is a common skin growth. It is felt to be the site of skin trauma. |
| TP | It is a small, bright red, glistening bump. It looks like a hemangioma, but with a thin white border where it meets the skin. Left untreated, pyogenic granulomas grow slowly and bleed easily when abraded by minor trauma. Frequently granulomata may be noted in the umbilicus after sloughing of the umbilical cord. |
| Dx | Diagnosis is made by inspection. |
| Tx | Treatment includes silver nitrate, electrocautery, or excision. See Nelson Essentials 194. |
| Thyroglossal Duct Cyst | |
|---|---|
| Pϕ | Thyroglossal duct cysts develop along the line of descent of the thyroid gland in the neck, anywhere from the base of the tongue to the sternal notch. |
| TP | They are usually midline, near the hyoid bone, in children 2 to 10 years of age. They are soft and smooth and may move when the child swallows. With infection, they become red and tender and may drain. |
| Dx | Diagnosis is usually made by inspection and palpation. Ultrasound and contrast neck CT may be useful. |
| Tx | If the cyst is infected, antibiotics (covering mouth and skin flora) are indicated. Surgical excision is the treatment of choice. See Nelson Essentials 50. |
| Cystic Hygromas | |
|---|---|
| Pϕ | Cystic hygromas are cystic lymphatic malformations occurring in the posterior triangle of the neck. |
| TP | They are soft, mobile, and nontender. They vary in size, occur in the neck, and are often present at birth. Respiratory compromise can occur with large lesions. |
| Dx | Diagnosis is made by ultrasound or contrast neck CT. |
| Tx | Surgical excision is the treatment of choice. See Nelson Essentials 50. |
| Branchial Cleft Anomalies | |
|---|---|
| Pϕ | Branchial cleft anomalies are lesions occurring from defects in the development of the second branchial arch resulting in firm masses along the anterior border of the sternocleidomastoid muscle. |
| TP | Branchial cleft sinuses are painless and present with drainage at the junction of the middle and lower thirds of the sternocleidomastoid muscle. Cysts will be fluctuant, mobile, and nontender if the tract is blocked; or warm, red, and painful if infected. |
| Dx | Diagnosis is made by ultrasound or contrast neck CT. |
| Tx | Antibiotics are indicated if infected. Surgical excision is the treatment of choice. See Nelson Essentials 50. |
| Lymphadenopathy/Lymphadenitis | |
|---|---|
| Pϕ | Cervical lymphadenopathy is the most common reason for neck masses in children. Etiologies for lymphadenopathy include bacterial or viral infections from local, regional, or systemic disease. Supraclavicular lymphadenopathy is considered pathologic, and a biopsy of a supraclavicular mass should be performed. Lymphadenitis occurs when acute infection is present in the lymph node. Bacteria are the most common causes and include methicillin-resistant Staphylococcus aureus and group A beta-hemolytic streptococci, as well as anaerobes such as Peptostreptococcus. If located in the inguinal area, consider sexually transmitted diseases as a possible etiology. |
| TP | Usually one or more nodes are warm, red, tender, and enlarged. Often the cervical nodes are affected in children. |
| Dx | Diagnosis is usually made by inspection and palpation. Ultrasound, contrast neck CT, needle aspiration, and PPD may be helpful for correct diagnosis. |
| Tx | Antibiotics are indicated for infection. Incision and drainage may be required. See Nelson Essentials 99. |
| Ganglion Cysts | |
|---|---|
| Pϕ | Ganglion cysts arise from tendon sheaths or the synovium of a joint. |
| TP | Ganglion cysts are tense cystic masses that may present over the wrist, palm, or dorsum of the hand or fingers. Pain is a frequent complaint. In the lower extremities, ganglion cysts characteristically involve the ankle and feet. |
| Dx | Diagnosis is made by inspection and palpation. |
| Tx | Spontaneous resolution and recurrence occur. Surgical excision may be indicated. See Nelson Essentials 203. |
| Erythema Nodosum | |
|---|---|
| Pϕ | Erythema nodosum is a vascular hypersensitivity reaction that occurs in the subcutaneous fat. No obvious cause is found in 50% of cases. Infections, especially streptococcal disease, histoplasmosis, tuberculosis, and Yersinia are known causes. Medications, such as oral contraceptives, estrogens, and sulfas; and chronic inflammatory diseases, such as sarcoidosis and inflammatory bowel disease, are also associated with erythema nodosum. |
| TP | Red, dusky, or violaceous tender nodules usually present on the shins but can be located in other areas. |
| Dx | Diagnosis is made by visual inspection. Sometimes it may be difficult to distinguish from other inflammatory processes. However, erythema nodosum lacks systemic toxicity and the lesions are nondraining lesions, thereby making it easier to differentiate from other diseases. If in doubt, a biopsy may be helpful. |
| Tx | Treatment includes identification and elimination of the cause, use of nonsteroidal antiinflammatory drugs, and elevation. See Nelson Essentials 97. |
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