Characteristics of mesenteric lymphadenitis in comparison with those of acute appendicitis in children

The Role of Neutrophil-to-Lymphocyte Ratio in the Diagnosis of Acute Appendicitis

BACKGROUND

Acute appendicitis (AA), a common reason for episodes of acute abdomen, is a surgical emergency. Its immediate diagnosis and management are of immense significance, as its diagnosis can become challenging at times, especially in resource-limited setups. The goal of this study was to ascertain the threshold value for the neutrophil-to-lymphocyte ratio (NLR) in diagnosing AA and to calculate the validity parameters for the NLR.

METHODOLOGY

 A cross-sectional study was carried out involving 108 patients who were admitted to the surgical wards of Ayub Teaching Hospital, Abbottabad with suspicion of AA and subsequently underwent open appendectomy. Data was collected regarding the demography of the patients, physical examination findings, clinical presentations, and investigations including the histopathology and complete blood count, from which the NLR value was computed, and the Statistical Package for Social Sciences (SPSS), version 25.0 (IBM Corp., Armonk, NY) was utilized for the computation. Receiver operating characteristic (ROC) analysis was done to calculate the cut-off value of the NLR for diagnosing AA, and validity parameters were computed, taking into account statistical significance with a p-value < 0.05.

RESULTS

Based on the ROC analysis, a threshold value for NLR indicating a positive appendectomy was determined to be 2.49 (sensitivity = 71.4% and 1-specificity = 12.5%) with an area under the curve of 90.6% (95% confidence interval {CI} 0.818-0.994, p<0.001). The sensitivity, specificity, and diagnostic accuracy of NLR for diagnosing AA were 71.43%, 87.5%, and 72.73%, respectively.

CONCLUSION

 There is a strong correlation between NLR at a cut-off value of 2.49 and the diagnosis of AA. We suggest that NLR should be utilized as a complementary biomarker to clinical examination, aiding in the diagnosis of AA.

Study on the mechanism of Ginseng-Gegen for mesenteric lymphadenitis based on network pharmacology

BACKGROUND

This study aimed to determine the main active ingredients of the Ginseng-Gegen (Panax Ginseng-Radix Puerariae) drug pair, to predict relevant action targets, and to establish a network of "drug-active ingredients-targets", to ultimately explore the mechanism of Ginseng-Gegen in the treatment of mesenteric lymphadenitis.

METHODS

The Traditional Chinese Medicine Systems Pharmacology (TCMSP) platform was used to screen the chemical constituents of Ginseng-Gegen, and the active ingredient targets were retrieved by UniProt database. The databases of GeneCards and the Online Mendelian Inheritance in Man (OMIM) were applied to search for mesenteric lymphadenitis-related targets. Cytoscape software was used to construct the network of active ingredient-action targets. The biological functions of the targets were analyzed in the Database for Annotation, Visualization, and Integrated Discovery (DAVID) database.

RESULTS

A total of 26 potential active ingredients of the Ginseng-Gegen drug pair were screened, with 128 drug-related targets and 255 mesenteric lymphadenitis-related targets. After matching, 23 potential targets were obtained for treating mesenteric lymphadenitis. Among them, MOL012297 (puerarin), MOL005344 (ginsenoside Rh2), and MOL000358 (beta-sitosterol) were linked to 3 or more key target genes. They were supposed to be important ingredients of Ginseng-Gegen in the treatment of mesenteric lymphadenitis.

CONCLUSIONS

Ginseng-Gegen is related to oxidative stress and inflammation, and it is a part of the nuclear factor κB (NF-κB) signaling pathway, tumor necrosis factor (TNF) signaling pathway, and the advanced glycation end products/receptor for advanced glycation end products (AGE-RAGE) signaling pathway. These biological processes and signaling pathways may be potential mechanisms of Ginseng-Gegen for treating mesenteric lymphadenitis.

Determination of Factors to Distinguish MIS-C from Acute Appendicitis in Children with Acute Abdominal Pain

INTRODUCTION

 The aim of this study was to make the differential diagnosis between acute appendicitis and multisystem inflammatory syndrome in children (MIS-C) for patients presenting with the complaint of acute abdominal pain (AAP) and to identify the determining factors for the diagnosis of MIS-C.

MATERIALS AND METHODS

 Eighty-one children presenting with AAP/suspected AAP were evaluated. Of these, 24 (29.6%) were included in the MIS-C group (MIS-C/g) and 57 were included in the suspected appendicitis group (S-A/g), which consisted of two subgroups: appendicitis group (A/g) and control observation group (CO/g).

RESULTS

 Comparing MIS-C/g, A/g, and CO/g, duration of abdominal pain (2.4, 1.5, 1.8 days), high-grade fever (38.8, 36.7, 37°C), severe vomiting, and severe diarrhea were higher in MIS-C/g. Lymphocytes count (LC) was lower, while values of C-reactive protein (CRP), ferritin, and coagulopathy were higher in MIS-C/g (p < 0.05). The optimal cutoffs for the duration of abdominal pain was 2.5 days; the duration of fever, 1.5 days; peak value of fever, 39°C; neutrophil count, 13,225 × 1,000 cell/µMoL; LC, 600 × 1,000 cell/µMoL; ferritin, 233 µg/L; and D-dimer, 16.4 mg/L (p < 0.05). The optimal cutoff for CRP was 130 mg/L (sensitivity 88.9, specificity 100%, positive predictive value 100%, NPV, negative predictive value 92.5%, p < 0.001). All patients in MIS-C/g tested positive by serology by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

CONCLUSION

 The duration of abdominal pain, presence of high-grade and prolonged fever, and evaluation of hemogram in terms of high neutrophil count and low LC exhibit high sensitivity and negative predictive value for MIS-C presenting with AAP. In case of doubt, inflammatory markers such as CRP, ferritin, D-dimer, and serology for SARS-CoV-2 should be studied to confirm the diagnosis.

Acute appendicitis–advances and controversies

Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.

Identifying threshold sizes for enlarged abdominal lymph nodes in different age ranges from about 200,000 individual's data

The threshold size for enlarged abdominal lymph nodes (E-ALNs), a common pediatric disorder, has yet to be standardized. According to the maximum short-axis diameter, this study divided ALNs into Grade A (≥ 10 mm), Grade B (8–10 mm), Grade C (5–8 mm), and Grade D (< 5 mm, normal). To identify the threshold size for E-ALNs, the prevalence of each grade was compared between asymptomatic individuals and symptomatic (e.g., abdominal pain) individuals without other diseases (e.g., appendicitis) that could explain the symptoms for different ages using data from > 200,000 individuals. The results showed the following: (1) For ages 1–3 years, the recommended threshold size is 8 mm, as the differences in the prevalence between the two groups were nonsignificant for Grade C but significant (p < 0.05) for both Grades A and B. (2) For ages 3–14 years, the recommended threshold size is 5 mm, as the differences between the two groups were significant (p < 0.05) for Grades A, B, and C. (3) The prevalence of Grades A, B, and C was very low for ages 0–1 years and high for ages 1–6 years. (4) The prevalence for males was generally higher than that for females for Grades A and B.

Reference intervals of mesenteric lymph node size according to lymphocyte counts in asymptomatic children

There is no acknowledged reference interval of mesenteric lymph node size in healthy children, and the size criterion for mesenteric lymph node enlargement (MLNE) has long been controversial. This study aimed to explore the reference intervals of mesenteric lymph node size according to lymphocyte counts in asymptomatic children and to develop a more appropriate definition of MLNE. The asymptomatic children included were divided into five age strata: 2 to 3 yr; 3 to 4 yr; 4 to 5 yr; 5 to 6 yr; and 6 to 7 yr. Correlation analyses between lymphocyte counts and the long-axis diameter, short-axis diameter, and average diameter of the largest mesenteric lymph node (LMLN) were performed. A reference interval of the short-axis diameter of LMLN was established according to this correlation analysis in each age group. We also report a reference interval of lymphocyte count in each age group. This study revealed significant correlations between the short-axis diameter of LMLN and lymphocyte count in all age groups, as well as in subdivided boy groups and girl groups. The overall reference interval of the short-axis diameter of LMLN in children was 0.54 cm—1.03 cm, with mean value of 0.75 cm. This study supports the use of the short-axis diameter greater than 8–10 mm as the diagnostic criterion for primary mesenteric lymphadenitis based on the presence of a cluster of three or more mesenteric lymph nodes and in the absence of other abnormalities.

Acute mesenteric lymphadenitis in children: findings related to differential diagnosis and hospitalization

INTRODUCTION

Diagnostic discrimination between acute appendicitis (AA) and mesenteric lymphadenitis (AML) may require more diagnostic tests or great skill after excluding other diagnoses. This study aimed to make a differential diagnosis between AA and AML patients with previous and new parameters and to examine which parameters should be taken into account regarding whether the AML patient should be hospitalized or discharged.

MATERIAL AND METHODS

One hundred and twenty-three AML and 134 AA patients, randomly selected, were included in the study. Demographic, clinical, and laboratory data of all subjects were analyzed. Ultrasonographic and rarely computed tomography examinations evaluating for the enlarged lymph nodes with the shortest diameter in the right lower quadrant of the AML patients were performed. Also, the erect abdominal radiographs (EAR) of AML and AA patients were evaluated.

RESULTS

While there was no statistically significant difference in age or gender, C-reactive protein, white blood cell count, monocyte percentage as well as symptoms between the AA and AML groups (p > 0.05), neutrophil and lymphocyte percentage, appearance of EAR and L/M ratio were significantly different between the two groups (p < 0.05). There was no correlation between the short-axis diameter of the mesenteric lymph node and clinical and laboratory findings in the AML group (p > 0.05).

CONCLUSIONS

Based on the results with ROC curve analysis, we propose to take into account the L/M ratio and the EAR from the parameters in the differential diagnosis between AA and AML in addition to previously reported parameters. Also, we recommend that the same features may be used to decide whether AML patients under observation are hospitalized or not.

Course of acute nonspecific mesenteric lymphadenitis: single-center experience

Available reports dealing with acute nonspecific mesenteric lymphadenitis do not address the total duration of symptoms. However, it is commonly assumed a time for recovery ≤ 4 weeks. The purpose of this report was to investigate the course of acute nonspecific mesenteric lymphadenitis in childhood. A review was made of the patients aged ≤ 16 years in whom the diagnosis of acute nonspecific mesenteric lymphadenitis was established between 2011 and 2015 at the Pediatric Emergency Unit. The records of the Pediatric Emergency Unit, those of the referring family doctors, and the results of a structured telephone interview with each family were used. Forty-four patients (25 girls and 19 boys) aged 2.5 to 16, median 8.2, years were included. A bimodal distribution in duration of symptoms was observed: symptoms persisted for ≤ 2 weeks in 22 patients and 3 to 10 weeks in 22. Clinical and laboratory characteristics were similar in children with symptoms persisting for 2 weeks or less 28 and in those with symptoms persisting for 3-10 weeks.

CONCLUSION

In patients affected with acute nonspecific mesenteric lymphadenitis, it is advantageous to think of the time span for recovery in terms of ≥ 4 weeks. What is Known: • Mesenteric adenitis is a self-limiting inflammatory condition with well-characterized clinical presentation and imaging features. • A total duration of symptoms of ≤ 4 weeks is usually hypothesized. What is New: • Symptoms persist for 3 to 10 weeks in half of the patients. • At presentation, clinical and laboratory characteristics are similar in children with symptoms persisting for 2 weeks or less and in those with 45 symptoms persisting for 3-10 weeks.