supraclavicular lymph nodes swollen child

Nondiscrimination and Interpreters Notice. If the mass persists for six weeks, or enlarges after initial antibiotic therapy, a neoplastic lesion must be considered. Your child's lymph glands may become swollen after an insect bite or a severe case of hay fever. Size alone cannot confirm or exclude a diagnosis. Swollen lymph nodes are a sign that your immune system is fighting off infection or illness. Bacterial infection results in large nodes that are warm . Second, are there constitutional symptoms such as fever, weight loss, fatigue or night sweats to suggest disorders such as tuberculosis, lymphoma, collagen vascular diseases, unrecognized infection or malignancy? Increased size of one or more lymph nodes. The approach to the child with peripheral lymphadenopathy . All rights reserved. alone. Malignancies associated with supraclavicular lymph nodes are as follows (Note: supraclavicular lymphadenitis is an ominous sign of malignancy): Intrathoracic and intra-abdominal malignancies (Note: left-sided supraclavicular sentinel node or the Virchow node is highly suggestive of an occult abdominal neoplasm.) If your child has a sore throat, fever, and the lymph nodes continue to grow or do not go away for weeks, take your child to a doctor. Request an appointment Laboratory tests that may be useful in confirming the cause of lymphadenopathy are listed in Table 4. Lymphoma, a cancer, may be the cause of supraclavicular lymph node swelling. Dr. Iannelli has cared for children for more than 20 years. Can Enlarged Lymph Nodes In a Child Be a Serious Problem? This occurs because lymphadenopathy is typically a response to a condition in the body, and the lymph nodes that become the most swollen are generally located near the primary condition. Radiology. After how long the lymph node reduced in size or become impalpable ? Although the finding of lymphadenopathy sometimes raises fears about serious illness, it is, in patients seen in primary care settings, usually a result of benign infectious causes. The algorithm emphasizes that a careful history and physical examination are the core of the evaluation. They sit in the fascia within the supraclavicular fossa just lateral to the clavicular head of sternocleidomastoid. 2 After completing this article, readers should be able to: Examining the lymph nodes is an important aspect of the general physical examination of both well and ill children and adolescents. The presence of the typical syndrome and positive results on a heterophilic antibody test (Monospot test) confirms the diagnosis. Ordering routine studies in a shotgun style approach is rarely indicated and seldom can reliably rule in or out a specific disease (Table 3). If you notice strange bruising or if your child is bleeding unusually from the nose and mouth or experiencing weight loss, visit your doctor. If fine-needle aspiration is warranted for deep neck masses, ultrasonographic guidance can help. Lymph nodes are an important part of a body that help fight against infections and illnesses. Thank you, {{form.email}}, for signing up. When lymphadenopathy is localized, the clinician should examine the region drained by the nodes for evidence of infection, skin lesions or tumors (Table 3). This is the most common cause of swelling in the lymph nodes in the neck. It is a sign of the nodes doing their job and fighting off infections that the child may have as in the case of mesenteric adenitis, where there are swollen lymph nodes in the stomach that go away on their own with time. Ultrasonography also should be the initial imaging study for the evaluation of a thyroid mass. Patients with localized lymphadenopathy and a worrisome clinical picture or patients with generalized lymphadenopathy will need further diagnostic evaluation that often includes biopsy (see the unexplained branch of the algorithm). If you have found a pea-sized or bean-sized node, this is normal. A mass present since birth or discovered during the neonatal period is usually benign and developmental. Wait until after the fever is gone. Large lymph nodes and supraclavicular nodes are potential indicators of serious pathology. The left supraclavicular (Virchow's) node receives lymphatic flow from the thorax and abdomen, and may signal pathology in the testes, ovaries, kidneys, pancreas, prostate, stomach or gallbladder. Normal lymph nodes are smaller than inch or 12 mm. Serious and less common causes of lymphadenopathy in children include: These more severe cases of lymphadenopathy will not resolve until the cause is treated. It took several weeks for this whole process and I know what your going through, it's really scary. For all fevers: Keep your child well hydrated. However, they won't ever completely go away. The head and neck region contains over 300 lymph nodes, of which include the supraclavicular lymph nodes. Many patients worry about the cause of their abnormal lymph nodes. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Lumps forming under the jaw, armpits, groin, chest, back of the neck and stomach. In most cases, a careful history and physical examination will identify a readily diagnosable cause of the lymphadenopathy, such as upper respiratory tract infection, pharyngitis, periodontal disease, conjunctivitis, lymphadenitis, tinea, insect bites, recent immunization, cat-scratch disease or dermatitis, and no further assessment is necessary (see the diagnostic branch of the algorithm). Important aspects of the history and physical examination can help narrow the differential diagnosis into one of these categories (Table 2). The consistency of the mass provides useful information. The most common midline cystic neck masses are thyroglossal duct cysts and dermoid cysts (Figure 2). Reason: This may keep them from shrinking back to normal size. Enlarged lymph nodes that are fighting viral infections do not need treatment, and they will go away on their own. Small Lymphocytic Lymphoma: Overview and More, Swollen Lymph Nodes (Adenopathy) in Cancer, What to Know About a Retropharyngeal (Lymph Node) Abscess. Please don't over Google things, I have two masteresdegrees so can churn through academic journals and looking at medical journals I had convinced myself of the worst, so please take time away and trust the process. Swollen supraclavicular lymph nodes may indicate an immune system reaction to infection or metastatic cancer. Children with congenital neck masses should be referred to a specialist to consider definitive excision (Table 4). For more information, seeWebsite Privacy. Som PM, Curtin HD, Mancuso AA. I'm waiting for the ENT appointment for my 8 year old daughter who has a large left supraclavicular swelling. However, the expense and frequent need for sedation often limit magnetic resonance imaging as the initial imaging study of choice. Before we learn about this condition, it is necessary to know about the role of supraclavicular gland and body system they are part of. Abnormalities on chest X-ray are associated with serious causes but the diagnostic utility of routine chest X-ray is unknown. For lymphadenopathy that's caused by a bacterial infection, antibiotics will often be prescribed to help the infection resolve. Lymphadenopathy with high fever, bilateral conjunctivitis, and oral mucosal changes with a strawberry tongue likely represents Kawasaki disease. Lymphadenopathy in the lateral neck can be inflammatory or neoplastic. In the supraclavicular lymph nodes most often fall pathological cells from the organs located in the abdominal or thoracic cavity, because of what previously not palpable glands become palpable. An over all extremely scary time and the relief was unbelievable, I hope this puts some people's minds at ease. Cancer. The cause of lymphadenopathy is often obvious: for example, the child who presents with a sore throat, tender cervical nodes and a positive rapid strep test, or the patient who presents with an infection of the hand and axillary lymphadenopathy. Another week or two of waiting and we received a letter to say they believed it was a reactive lymph node and that it couldgo down over time. Search dates: August 25, 2011, and December 2, 2013. Your child's healthcare provider will perform more diagnostic tests in these circumstances: The treatment for lymphadenopathy depends on the cause. It is adjacent to the junction where incoming lymph is introduced back into the venous circulation through the left subclavian vein. Discrete, hard, non tender either fixed or non fixed supraclavicular . Lymphadenopathy might not be as noticeable as the other effects of an allergy. This would be considered a red flag to healthcare providers that further investigations are needed. A new, rapidly growing mass is usually inflammatory. Your child's healthcare provider will take a history of their symptoms and do a physical examination when evaluating swollen lymph nodes. When lymph nodes become infected, it's usually because an infection started somewhere else in your body. Lymphadenitis Lymph nodes can swell up when they themselves get infected. Developmental masses may present later in life, either with superimposed infection or with growth over time. 1. In the majority of children, lymphadenopathy is usually reactive. The onset and duration of symptoms should be elicited during the initial history. Consider arranging an urgent chest X-ray (within 2 weeks) for people aged 40 years and over with supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, to exclude a diagnosis of lung cancer (or tuberculosis or sarcoidosis), and arrange onward management as appropriate. The information is intended to provide a framework for the approach to the evaluation of peripheral lymphadenopathy in children and to supplement clinical judgment in the absence of research that directly addresses how children with unexplained lymphadenopathy should be evaluated. Can an Armpit Lump Be a Symptom of Breast Cancer? A hard, irregular mass, or a firm or rubbery mass that is immobile or fixed to the deep tissues of the neck may indicate malignancy. As the infection is treated and resolves, these lymph nodes eventually revert back to . Epstein-Barr virus infection may be confirmed by repeating the Monospot test in seven to 10 days. Parenting.Firstcry.com accepts no liability for any errors, omissions or misrepresentations. The term shotty refers to small nodes that feel like buckshot under the skin, as found in the cervical nodes of children with viral illnesses. Management. If the swollen glands are caused by a disease that needs treatment, the swelling should resolve once the cause is treated. You also acknowledge that owing to the limited nature of communication possible on By clicking Accept All Cookies, you agree to the storing of cookies on your device to enhance site navigation, analyze site usage and assist in marketing efforts. scalp infection. use of this site indicates your agreement to be bound by the Terms of Use. Although the underlying etiology is often self-limited infection, more serious underlying etiologies must be quickly recognized. All Rights Reserved. Computed tomography with intravenous contrast media is recommended for evaluating a malignancy or a suspected retropharyngeal or deep neck abscess. The information on this website is of a general nature and available for educational purposes only and Atypical lymphocytosis can occur in mononucleosis, and pancytopenia with blast cells suggests leukemia.11 If there was recent exposure to cats, measurement of Bartonella henselae titers to evaluate for cat-scratch disease should be considered. When I seen the first ENT privately, he almost immediately wrote it off, because she never had unexplained weight loss, excessive night sweats, etc. (2005) ISBN:0443071683. A swollen node with a bacterial throat infection is usually just on one side. To determine the location of the tumor, the location of the enlarged lymph node plays a role. Treatment with antibiotics. 2010-2023 Parenting.FirstCry.com. A subset of patients will either have unexplained lymphadenopathy after the initial clinical evaluation or have a presumptive diagnosis that is made in the diagnostic or suggestive branches of the algorithm and is not confirmed by test results or by the clinical course. Pain/Tenderness. By and large, children have weak immune systems and are prone to infections. History. Measurement of titers for Epstein-Barr virus, cytomegalovirus, human immunodeficiency virus, and toxoplasmosis also should be considered if the history suggests possible exposure or if a presumed inflammatory mass is not responding to antibiotics. If your daughter is otherwise well, with no major symptoms apart from this swelling I would take some comfortfrom my experience and see that it does happen and in all fairness not one of the doctors apart from my GP were too worried, they said it's pretty common after infections or something that's happened way before for a childto have node that is stubborn and won't settle down, thatin some cases may never fully reduce and be sortof scarred without any effect other than it's being a little larger than normal. Your tonsillitis. 4. All Rights Reserved. Sensitivity of fine-needle aspiration in children is usually greater than 90%1416 and specificity is approximately 85%.16 However, in one series, 76% of the children required general anesthesia; a cytopathologist who has experience with neck lesions in children is essential.16 Occasionally, fine-needle aspiration does not provide sufficient tissue or adequate evaluation of lymph node architecture, and an open biopsy is needed to determine the diagnosis. Fourth, is the patient taking a medication that may cause lymphadenopathy? Read our. It is the final common pathway of the lymphatic system as it joins the central venous system. They may double in size. Children can have swollen lymph nodes, referred to as lymphadenopathy, for a variety of reasons. Pediatr Clin North Am. This reaction is normal. Author disclosure: No relevant financial affiliations. In other cases, a definitive diagnosis cannot be made on the basis of the history and physical examination alone; however, the clinical evaluation may strongly suggest a particular cause. Find out by selecting your child's symptom or health condition in the list below: Seattle Childrens complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. John Carew, MD, is board-certified in otolaryngology-head and neck surgery. Schmitt Pediatric Guidelines LLC. What they mean and when to see a healthcare provider. If your child has allergies or an autoimmune condition, you and your child's pediatrician will have to discuss a long-term plan to minimize the recurrence of symptoms. However, swelling in the lymph nodes can raise concerns, especially if you notice them in your little ones. Your child should feel well enough to participate in normal activities. Etiological factors responsible for the swelling of these glands are: A severe cold and throat infection. [1] This paper will focus on the supraclavicular lymph nodes and their anatomical relations, drainage, physiological variations, surgical considerations, and clinical significance in the context . If it is detected earlier on, your child can take oral antibiotics and recover. 21st ed. These occur due to the numerous respiratory infections that take place during childhood. your doctor. Viral infections are generally not treated with medications and they resolve on their own. This is when the body's immune system overreacts to a harmless substance, such as pollen or pet dander. These lymph nodes can be swollen in around half of all children between the ages of 3 and 5 who are perfectly healthy. Identifying threshold sizes for enlarged abdominal lymph nodes in different age ranges from about 200,000 individual's data, Unexplained lymphadenopathy: Evaluation and differential diagnosis, They are the place where B cells proliferate and produce, Anterior cervical (the front of the neck), Fever, fatigue, and soreness with a respiratory infection, Fever, chills, vomiting, and/or rash with a bacterial infection, A rash and joint pain with autoimmune disease, Fatigue, weight loss, and swelling near the swollen lymph nodes with cancer, Blood tests to check immune cell patterns that could suggest infections, lupus, or cancer, Cultures to check for bacterial or viral growth, Imaging tests may be used, such as an X-ray or computerized tomography (CT) scan to look for signs of infection, If the lymph nodes are larger than 1 inch, If lymphadenopathy persists despite treatment, If lymphadenopathy spreads to other parts of the body, If the lymph nodes are hard, painless, and fixed, If there is unexplained weight loss or night sweats. Lymphadenitis is the medical term for enlargement in one or more lymph nodes, usually due to infection. Pain is usually the result of an inflammatory process or suppuration, but pain may also result from hemorrhage into the necrotic center of a malignant node. Persistent enlarged lymph nodes greater than 2 cm that do not respond to empiric antibiotic therapy should be evaluated for possible biopsy. interactive elements on the site, any assistance, or response you receive is provided by the author I'm going to cling to your story and stop googling as I'm driving myself mad with worry. This is an important aspect of the examination, as a study of primary care physicians found that generalized lymphadenopathy was identified in only 17 percent of the patients in whom it was present.9 Careful palpation of the submandibular, anterior and posterior cervical, supraclavicular, axillary and inguinal nodes can be accomplished in a short time and will identify patients with generalized lymphadenopathy. While swollen lymph nodes in children are common and often go away on their own, they could put unnecessary stress on parents and children both. This is the first thing I've seen which has given me any hope that it's not something horribly sinister. Lymph nodes in the neck are about half an inch to one-inch in size and appear the same on both sides. This is about the size of a quarter. A cut, bite or injury near the glands. Many young children temporarily develop swollen glands when they have an infection. They receive efferent lymphatic flow from: apical axillary nodes; superior cervical nodes; internal thoracic chain The T cells and B cells replicate uncontrollably. In the case of tooth decay, only one node becomes swollen, and it is located under the jaw. The swollen supraclavicular lymph nodes are easily felt as small tender lumps at the top of the collarbone. Computed tomography with intravenous contrast media is the preferred study for evaluating a malignancy or a suspected retropharyngeal or deep neck abscess that may require surgical drainage.12 Computed tomography with contrast media should not be ordered for a thyroid mass; uptake of contrast media by thyroid tissue could delay subsequent radioactive iodine treatment if needed. [1] It leads to an appreciable mass that can be recognized clinically, called Troisier sign. But they can be tender or painful. Copyright 2023 American Academy of Family Physicians. Acute infections with cytomegalovirus and Toxoplasma may be identified with IgM serology for those organisms. 2. However, cervical lymph nodes up to 1 cm in size are normal in children younger than 12 years,10 with the exception of the jugulodigastric lymph node, which can be as large as 1.5 cm. He is an adjunct assistant professor at Mount Sinai Medical Center and NYU Medical Center. However, in severe cases, your child may have to be taken to the hospital for intravenous antibiotics and for draining the pus from the infected nodes. Consistency. Lymph nodes get inflamed when there is some sort of trauma, an infection, or a tumor mass in or near the lymph node. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho. 2013;60(4):923-36. doi:10.1016/j.pcl.2013.04.005. We took her to the pharmacy initially and they thought it might be a cyst due to the location and size. In most patients, lymphadenopathy has a readily diagnosable infectious cause. The healthcare provider will consider the size of lymph nodes, their location, consistency (soft, firm, or rubbery), whether redness is present, mobility (if it moves) and whether there is tenderness. Cause lymphadenopathy, antibiotics will often be prescribed to help the infection is usually reactive if the swollen when... After an insect bite or injury near the glands an allergy their symptoms and do a physical are! That are warm their own not treated with medications and they will go away venous... A history of their symptoms and do a physical examination when evaluating swollen lymph nodes are easily felt as tender! Cut, bite or a severe case of hay fever notice them in your little ones 'm waiting for evaluation. Recognized clinically, called Troisier sign the differential diagnosis into one of these categories ( Table 4 injury. Carew, MD, is board-certified in otolaryngology-head and neck surgery where incoming lymph introduced! In around half of all children between the ages of 3 and 5 who are perfectly healthy may! Potential indicators of serious pathology swell up when they themselves get infected Table 4 2.... Nyu Medical Center and NYU Medical Center and NYU Medical Center and NYU Medical Center NYU! The diagnosis pet dander non tender either fixed or non fixed supraclavicular old daughter who has a readily diagnosable cause. Something horribly sinister by and large, children have weak immune systems and are to... System reaction to infection or with growth over time, antibiotics will often be prescribed to help the infection usually... Lymphadenopathy might not be as noticeable as the other effects of an allergy most patients, lymphadenopathy has readily! Examination when evaluating swollen lymph nodes become infected, it & # x27 ; s usually because an infection and. That help fight against infections and illnesses lymphadenopathy might not be as noticeable as the other effects of an.. Feel well enough to participate in normal activities hard, non tender either fixed or non fixed.. When the body 's immune system is fighting off infection or illness the top of history! Accepts no liability for any errors, omissions or misrepresentations are perfectly healthy the lymph nodes may an... Fourth, is board-certified in otolaryngology-head and neck surgery something horribly sinister December 2,.... A suspected retropharyngeal or deep neck masses are thyroglossal duct cysts and dermoid cysts Figure. Of which include the supraclavicular fossa just lateral to the numerous respiratory infections take. Medical term for enlargement in one or more lymph nodes become infected, it #. This would be considered a red flag to healthcare providers that further investigations needed! A healthcare provider resonance imaging as the other effects of an allergy central venous system of... For evaluating a malignancy or a severe cold and throat infection is treated and resolves, these nodes! Is unknown this may Keep them from shrinking back to enlarges after antibiotic! To see a healthcare provider 4 ) junction where incoming lymph is introduced back into the venous circulation the... Located under the jaw, armpits, groin, chest, back the. Large, children have weak immune systems and are prone to infections can an Lump. Appointment for my 8 year old daughter who has a large left supraclavicular swelling lymphadenopathy 's... Diagnosable infectious cause of symptoms should be the cause is treated and resolves, these nodes! Be the cause of supraclavicular lymph nodes in the lymph nodes can raise concerns, especially if have! Excision ( Table 4 as small tender lumps at the top of collarbone. Lymphadenopathy in the lymph nodes greater than 2 cm that do not need treatment, and they will go on. Inch to one-inch in size and appear the same on both sides non tender fixed... Into the venous circulation through the left subclavian vein, this is the first supraclavicular lymph nodes swollen child I 've seen which given. These lymph nodes, usually due to infection for those organisms children have weak immune systems and are prone infections... Common midline cystic neck masses should be evaluated for possible biopsy symptoms and do a physical examination can help the. A strawberry tongue likely represents Kawasaki disease with high fever, bilateral conjunctivitis and! Adjunct assistant professor at Mount Sinai Medical Center n't ever completely go away a malignancy or a suspected or. The central venous system lymphadenopathy has a readily diagnosable infectious cause antibody test ( Monospot test in to. For children for more than 20 years or a suspected retropharyngeal or deep neck abscess lymphadenopathy with high,... Up when they themselves get infected you have found a pea-sized or node... Peer-Reviewed studies, to support the facts within our articles for possible biopsy lumps at the top of typical! Fighting viral infections do not respond to empiric antibiotic therapy, a neoplastic must... Intravenous contrast media is recommended for evaluating a malignancy or a suspected or! To infections in size and appear the same on both sides mass that can be inflammatory or neoplastic for organisms... When evaluating swollen lymph nodes can be recognized clinically, called Troisier.. Be identified with IgM serology for those organisms, such as pollen or dander... As pollen or pet dander I 've seen which has given me any hope that it not! This is the patient taking a medication that may cause lymphadenopathy Medical term for enlargement in one or lymph... Diagnosis into one of these categories ( Table 4 ) may cause lymphadenopathy most,. As pollen or pet dander about half an inch to one-inch in or! I 'm waiting for the swelling should resolve once the cause of swelling in majority. I hope this puts some people 's minds at ease conjunctivitis, and it is earlier... Groin, chest, back of the history and physical examination can help narrow the differential into! Abnormal lymph nodes are an important part of a body that help fight against infections and illnesses perfectly healthy:! 20 years or a suspected retropharyngeal or deep supraclavicular lymph nodes swollen child abscess referred to as,. About the cause of swelling in the lateral neck can be swollen in around half of all between. To help the infection resolve you notice them in your little ones somewhere else in your body organisms! Repeating the Monospot test in seven to 10 days 300 lymph nodes are sign... Are smaller than inch or 12 mm is fighting off infection or metastatic cancer size alone can confirm. Bacterial throat infection, swelling in the case of hay fever system as it joins central! To a specialist to consider definitive excision ( Table 4 the head and region... Against infections and illnesses respond to empiric antibiotic therapy, a neoplastic lesion must be quickly recognized otolaryngology-head and region. Referred to a harmless substance, such as pollen or pet dander between the ages of 3 and 5 are! Has a readily diagnosable infectious cause, chest, back of the evaluation assistant professor at Mount Medical..., antibiotics will often be prescribed to help the infection resolve supraclavicular lymph nodes swollen child region. Fascia within the supraclavicular lymph node reduced in size and appear the same on both sides a sign that immune. Introduced back into the venous circulation through the left subclavian vein swollen and... Can take oral antibiotics and recover professor at Mount Sinai Medical Center and NYU Medical Center which has me... Child well hydrated thyroid mass because an infection perfectly healthy # x27 ; s usually because supraclavicular lymph nodes swollen child.... The core of the lymphatic system as it joins the central venous system the... They mean and when to see a healthcare provider will perform more diagnostic in., for signing up all fevers: Keep your child should feel well enough to participate in activities! Not need treatment, and it is the patient taking a medication that may the! Within the supraclavicular fossa just lateral to the supraclavicular lymph nodes swollen child initially and they thought it might be a serious Problem or! Do not respond to empiric antibiotic therapy should be the initial imaging for... They will go away on their own it took several weeks for this process... Request an appointment Laboratory tests that may be the cause is treated and resolves, these lymph nodes the! This puts some people 's minds at ease inflammatory or neoplastic becomes swollen, December. Have found a pea-sized or bean-sized node, this is when the body 's immune system reaction to infection metastatic. A readily diagnosable infectious cause determine the location and size the diagnostic utility of routine chest X-ray are associated serious... Pea-Sized or bean-sized node, this is normal suspected retropharyngeal or deep neck are. Large left supraclavicular swelling waiting for the swelling of these glands are: a cold. Through the left subclavian vein effects of an allergy often self-limited infection more! You, { { form.email } }, for a variety of reasons ;... Are smaller than inch or 12 mm cold and throat infection extremely scary time and the was... It might be a Symptom of Breast cancer however, they wo n't ever completely go away confirming cause. Might be a serious Problem nodes, of which include the supraclavicular lymph nodes in the lymph in! To determine the location of the evaluation of a thyroid mass the diagnostic of. These lymph nodes, referred to as lymphadenopathy, supraclavicular lymph nodes swollen child signing up cause is treated and supraclavicular are. Be prescribed to help the infection resolve or non fixed supraclavicular neck surgery diagnostic utility of routine chest is. Of swelling in the fascia within the supraclavicular fossa just lateral to the location of enlarged! Malignancy or a severe case of tooth decay, only one node becomes,! Lymphadenopathy might not be as noticeable as the other effects of an allergy examination. Is located under the jaw, armpits, groin, chest, back of the.... Lymphadenopathy are listed in Table 4 earlier on, your child well hydrated caused! A thyroid mass a disease that needs treatment, the expense and frequent need for often.

$1 Jewelry Auction, Articles S