effusion may obscure a mass on both chest x-ray and chest CT scan Malignant pericardial effusions are most often associated with leukemias and lymphomas For general diagnosis and management of pulmonary and pericardial effusions see Chapters 86 Cardiac Emergencies and 99 Pulmonary Emergencies Askin tumor or metastatic sarcomas may present as a chest wall mass with or without pain More commonly, it presents with respiratory symptoms from an effusion TABLE 98.5 LYMPHOMA PRESENTATIONS AND CONSIDERATIONS IN THE ED Lymphoma Typical presentation Potential complications at diagnosis and considerations for ED management Hodgkin disease Painless, hard adenopathy: neck and supraclavicular common AMM common, with or without symptoms Pleural effusions uncommon May have “B” symptoms Fevers Night sweats Weight loss (at least 10% weight loss) Superior vena cava (SVC) syndrome Tracheal obstruction Lymphoblastic lymphoma Painless, hard adenopathy at any site Respiratory symptoms from rapidly growing mediastinal mass, often with pleural effusions (Tlineage, advanced stage) GI tract involvement rare Tumor lysis syndrome (TLS) SVC syndrome Tracheal obstruction Pleural effusions Burkitt lymphoma Single site of enlarged lymphoid tissue (low stage) Incidental finding on appendectomy Asymmetric enlarged tonsil Lead point for intussusception in >3 yrs A single, painless enlarged node Painless, hard adenopathy with rapid growth (usually advanced stage) Rapid assessment for TLS: High risk of severe tumor lysis, even prior to treatment (advanced stage) First dose rasburicase in ED if uric acid >8 and low risk for G6PD deficiency Urgent consultation with oncology Admission to center with available pediatric dialysis Rapidly progressing abdominal distention with diffuse involvement of the GI tract/liver with ascites and pleural effusions (advanced stage) Diffuse large B-cell Painless, hard adenopathy at lymphoma any site, neck/supraclavicular common AMM common, symptoms variable (advanced) Symptom progression can be rapid (advanced stage) Systemic symptoms of malaise, weight loss common with advanced disease GI symptoms/abdominal mass from GI tract and mesenteric nodes involvement Anaplastic large cell Painless, hard adenopathy at lymphoma any site Skin/subcutaneous nodules GI symptoms/abdominal mass from GI tract and mesenteric node involvement Systemic symptoms (fevers, night sweats, weight loss, malaise) common with advanced disease TLS SVC syndrome Tracheal obstruction TLS AMM, anterior mediastinal mass; G6PD, glucose-6-phosphate dehydrogenase Clinical Assessment There may be useful clues to the diagnosis from the history and physical examination A recent history of new-onset asthma in an older child who responded ... low risk for G6PD deficiency Urgent consultation with oncology Admission to center with available pediatric dialysis Rapidly progressing abdominal distention with diffuse involvement of the GI tract/liver