What should I do if my child has a rapidly spreading lump over the last 10 days?

Rapidly Spreading Lump in a Child: Urgent Medical Evaluation Required

A child with a rapidly spreading lump over the last 10 days requires immediate medical evaluation, preferably in an emergency department or urgent care setting, as this could represent a serious infection such as empyema or another condition requiring prompt intervention. 1

Initial Assessment

When faced with a rapidly spreading lump in a child, consider these key possibilities:

Possible Diagnoses to Consider

• Pleural infection/empyema: A rapidly spreading lump on the chest wall could represent a parapneumonic effusion or empyema, especially if accompanied by fever, cough, or respiratory symptoms 1
• Congenital melanocytic nevi: Unlikely to spread rapidly over 10 days 1
• Infantile hemangioma: Can grow rapidly but typically presents as a vascular lesion 1
• Abscess or cellulitis: May appear as a spreading lump with surrounding erythema
• Malignancy: Less common but concerning if rapid growth occurs

Immediate Actions

Warning Signs Requiring Emergency Evaluation

• Fever
• Respiratory distress (rapid breathing, difficulty breathing)
• Pain at the site of the lump
• Lethargy or decreased activity
• Spreading redness around the lump
• Systemic symptoms (decreased appetite, malaise)

Specific Evaluation Steps

1. Location assessment: The location of the lump provides critical diagnostic clues

   • Chest wall: Consider empyema or pleural infection 1, 2
   • Face or neck: Higher risk for airway compromise
   • Extremities: Consider soft tissue infection

2. Physical examination findings to note:

   • Size and rate of growth
   • Consistency (fluctuant vs. firm)
   • Overlying skin changes (erythema, warmth)
   • Tenderness
   • Regional lymphadenopathy

Management Algorithm

If Chest Wall Involvement with Respiratory Symptoms

If the lump is on the chest wall and accompanied by fever, cough, or respiratory symptoms:

1. Seek immediate medical attention - The British Thoracic Society recommends that all children with suspected parapneumonic effusion or empyema should be admitted to hospital 1

2. Diagnostic workup should include:

   • Chest radiograph
   • Ultrasound of the chest
   • Blood cultures
   • Complete blood count
   • C-reactive protein or ESR 1

3. Treatment typically involves:

   • Appropriate antibiotics
   • Possible drainage if empyema is confirmed
   • Supportive care including oxygen if needed 1

If Soft Tissue Infection Suspected

For a rapidly spreading lump with signs of infection (redness, warmth, tenderness):

1. Urgent medical evaluation
2. Possible interventions:
   • Antibiotics
   • Incision and drainage if abscess is present
   • Close follow-up to ensure resolution

If No Obvious Infection Signs

Even without obvious signs of infection, a rapidly spreading lump warrants prompt evaluation:

1. Medical evaluation within 24-48 hours
2. Imaging studies may include:
   • Ultrasound (first-line for soft tissue masses)
   • MRI if deeper structures are involved
   • CT scan if bone involvement is suspected

Important Considerations

• Do not delay seeking care: The British Thoracic Society emphasizes that if a child remains pyrexial or unwell 48 hours after treatment for pneumonia, re-evaluation is necessary with consideration given to possible complications like empyema 1

• Avoid manipulation: Do not squeeze or apply pressure to the lump as this may spread infection

• Watch for progression: Monitor for increasing size, spreading redness, or worsening symptoms

Follow-up

• Close follow-up is essential regardless of diagnosis
• For empyema, the British Thoracic Society recommends that children should be followed until they have recovered completely and their chest radiograph has returned to near normal 1
• For other conditions, follow-up timing will depend on the specific diagnosis

Pitfalls to Avoid

• Delaying medical attention: Rapidly spreading lumps require prompt evaluation
• Assuming it's "just a bruise": Rapid spread over 10 days is concerning and warrants medical assessment
• Missing underlying conditions: In some cases, the lump may be a manifestation of a systemic condition requiring comprehensive evaluation

Remember that the prognosis for most pediatric conditions is excellent with prompt and appropriate treatment, but delays in diagnosis and management can lead to increased morbidity.