A 3 year old female presents to her primary care physician with a chief complaint of a neck mass that has been present and getting worse over 4 days. The mass started as a small lump that has enlarged to the size of a walnut and is now becoming painful, and warm to touch with overlying redness. She has had 2 days of fever up to 104 degrees (40 degrees C). She is also complaining of a runny nose, cough and sore throat for 1 week. Her appetite for solid foods is down but she is drinking fluids well and her urine output is normal. She has not been as active as usual and has not slept well due to the fever. No one at home has been ill but she does attend pre-school and several children have been ill recently with sore throats and URI symptoms. Her history is negative for recent skin infection, skin rash, weight loss, dental problems or cavities, nausea, vomiting or diarrhea. There is no exposure to cats or other animals. Her past medical history, family history and social history are unremarkable.
Exam: VS T 40, P 110, RR 20, BP 80/40, oxygen saturation 100% in room air. Height and weight are at the 50th percentile. She is tired appearing but in no acute distress. Pupils are equal and reactive. Sclera is white and conjunctiva are clear. TMs are normal. Her throat is erythematous with patches of exudate on both tonsils. Some clear nasal mucus is noted within her nares. Her neck is supple with tender bilateral cervical lymphadenopathy. There is a 2 cm x 3 cm tender, warm anterior cervical lymph node on the right with overlying erythema. Fluctuance is present. No axillary or inguinal lymphadenopathy is appreciated. Heart is regular without murmurs. Lungs are clear. Abdomen is nontender and nondistended. No hepatosplenomegaly or masses are noted. Her extremities are warm with full pulses and capillary refill time of one second. No skin rashes or impetigo scars are noted. Neurologic exam is normal.
A throat swab is sent for beta hemolytic strep culture. CBC shows WBC of 25,000 with a left shift. She is started on IV clindamycin empirically. An ultrasound study shows abscess formation. A surgeon is consulted and the abscess is incised and drained (I&D) for a moderate amount of pus. Gram stain shows numerous WBCs and gram positive cocci. Culture of the pus grows out Strep pyogenes (group A strep) within 24 hours. Her throat culture also grows group A strep. Her antibiotics are changed to IV penicillin. She responds to the antibiotics and I&D with dramatic improvement. She is discharged after 3 days of hospitalization to complete a 10 day course of penicillin.
Lymphadenopathy is a common complaint that brings children to see a physician. Fortunately, most of these children will have a benign, self-limited process. However, some children with serious systemic disease or malignancy may present with lymphadenopathy. It is therefore important to understand the differential diagnosis, perform a thorough history and careful physical exam and be aware of the appropriate work up to undertake in a timely manner. Enlargement of a lymph node (lymphadenopathy) may be caused by proliferation or invasion of inflammatory cells (lymphadenitis) or by infiltration of malignant cells. The location of the enlarged lymph node can be helpful in the differential diagnosis. It is normal for healthy children to have palpable lymph nodes in the anterior cervical, axillary and inguinal areas. Palpable lymph nodes in the supraclavicular region; however, often reflect mediastinal malignancy.
Important questions to ask the patient/caregiver include location and duration of the enlarged lynch node (acute vs. chronic, localized vs. generalized), history of prolonged fever, weight loss, arthralgias, skin lesions/infections or rashes, history of recurrent infections, immunization status, contact with sick persons, recent travel, exposure to animals and insects, URI symptoms, sore throat and dental problems/cavities. On physical exam, pay particular attention to location, consistency (solid or fluctuant, smooth or nodular, movable or fixed), number, distribution and size. The appearance of the overlying skin should be noted (red and warm in infection, violaceous coloration in nontuberculous mycobacteria). Hepatosplenomegaly, bruises, petechiae, conjunctivitis, pharyngitis, periodontal disease, and signs of systemic disease should be looked for.
The term "shotty" is commonly used to describe lymphadenopathy. Shotty means shot-like, which refers to bird shot (tiny beads) or buck shot (bigger beads). Shotty lymphadenopathy could refer to a matting of lymph nods with tiny bumps, medium bumps or big bumps. This term is vague and it may be preferable to use more accurate terminology.
Most patients with lymphadenopathy clinically assessed to be due to a minor infection do not require any laboratory testing. Laboratory work up to consider in a patient with a potentially more serious presentation of lymphadenopathy includes PPD, HIV screening, throat culture, CBC, blood culture. Serologic studies for EBV (Epstein-Barr virus), CMV (cytomegalovirus), HIV, Treponema pallidum, Toxoplasma gondii, or Brucella can be helpful in selected cases. For a patient with a fluctuant node where an abscess is suspected, ultrasound may be helpful. Needle aspiration of a suspected abscess may negate the need for an ultrasound but this approach is more invasive. Although a needle aspirate can yield the organism contained within an abscess, most abscesses will have to be surgically drained anyway. Occasionally, a lymph node biopsy may be needed. This tissue is usually sent for gram stain, bacterial culture, acid fast stain, mycobacterial culture, or Bartonella henselae (cat scratch disease) PCR. A chest x-ray evaluation should also be considered to rule out mediastinal masses/malignancy.
The differential diagnosis for lymphadenopathy is best based upon the presentation as either acute bilateral cervical lymphadenitis, acute unilateral pyogenic (suppurative) lymphadenitis, and chronic cervical lymphadenopathy. The most common causes of acute bilateral cervical lymphadenitis are URI viruses such as adenovirus, influenza and RSV. Viruses that typically cause generalized lymphadenopathy such as EBV and CMV may also present as acute bilateral cervical lymphadenitis. The most common causes of acute unilateral pyogenic (suppurative) lymphadenitis are Staph aureus and group A strep. Most of these children are 1-4 years of age. The typical clinical course of lymphadenitis due to group A strep, is manifested in association with group A strep tonsillitis, both of which respond to penicillin. Abscess formation and the need for surgical drainage are uncommon with group A strep. However, Staph aureus more commonly forms abscesses and I&D will almost always be necessary. If there is a prior history of dental problems or a dental abscess, anaerobic oral flora may be the cause. The differential diagnosis for chronic cervical lymphadenopathy is more extensive. The most common causes of prolonged cervical lymphadenopathy are infectious such as atypical mycobacterial infections, mycobacterium tuberculosis, cat scratch disease, EBV, CMV, toxoplasmosis, histoplasmosis and HIV. Noninfectious etiologies for chronic cervical lymphadenopathy include malignancy such as leukemia, lymphoma, metastatic solid tumors such as neuroblastoma, rhabdomyosarcoma and nasopharyngeal carcinoma. One other important etiology that does not fall into the above categories is Kawasaki disease. Kawasaki disease is associated with a single, nontender, nonpurulent enlarged cervical lymph node.
Since most cases of acute bilateral cervical lymphadenitis are viral in etiology and self -limited, only symptomatic treatment is recommended. For children with acute unilateral pyogenic (suppurative) lymphadenitis caused by Staph aureus or group A strep who do not appear toxic and have no apparent abscess or cellulitis oral empiric therapy with cephalexin, oxacillin or clindamycin is recommended. For ill appearing children who have abscess formation or cellulitis, needle aspiration or I&D and IV therapy with clindamycin or vancomycin is recommended. For children who have cervical lymphadenitis associated with periodontal disease, needle aspiration or I&D and therapy with penicillin or clindamycin are optimal. For suspected nontuberculous mycobacteria infection, surgical excision of the infected lymph node without antibiotic therapy is optimal. For cat scratch disease following needle aspiration and PCR diagnosis of Bartonella infection, no antibiotic therapy is routinely recommended, although this is controversial since azithromycin has some clinical efficacy.
The prognosis for lymphadenopathy and lymphadenitis depends upon the etiology. In general, since most childhood acute bilateral cervical lymphadenopathy is viral in etiology, the prognosis is good. Since most acute unilateral pyogenic (suppurative) lymphadenitis is caused by Staph aureus and group A strep, and is easily treatable, the prognosis is also good. Since the differential diagnosis for chronic cervical lymphadenopathy is more extensive, generalized statements about prognosis are difficult to make.
Lymphangitis is the inflammation of the lymphatic vessels. The etiology of lymphangitis can be neoplastic or benign. If the lymphatic vessels are infiltrated by tumor cells, surrounding fibrosis takes place producing visible or palpable cords. Lymphangitis is sometimes seen proximal to areas of cellulitis (especially those caused by group A strep) as red streaks extending from the cellulitis proximally. Such cases are treated similar to cellulitis alone.
1. What are the indications for biopsy of a lymph node?
2. What is the most common cause of acute bilateral cervical lymphadenopathy in children?
3. What is the most common cause of acute unilateral cervical lymphadenitis associated with fever and suppuration?
4. What is the most appropriate treatment of suppurative cervical lymphadenitis caused by nontuberculous mycobacteria?
5. What are some causes of prolonged cervical lymphadenitis in children?
1. Liu JH. Chapter 15.5-Evaluation of Head and Neck Masses. In: Rudolph AM (ed). Rudolph's Pediatrics, 21st edition. 2003, New York: McGraw-Hill, pp. 1279-1281.
2. Twist CJ. Assessment of lymphadenopathy in children. Pediatr Clin North Am 2002;49(5):1009-1025.
3. Peters TR, Edwards KM. Cervical Lymphadenopathy and Adenitis. Pediatr Rev 2002;21(12):399-405.
Answers to questions
1. Persistent enlargement despite empiric therapy, persistent enlargement or no improvement with negative laboratory work up, solid fixed mass, mass located in the supraclavicular area, accompanying constitutional signs of persistent fever or weight loss.
2. Self limited, systemic viral infections such as adenovirus, influenza, and RSV are most common. EBV and CMV also can present as acute bilateral cervical lymphadenitis.
3. Staph aureus and Strep pyogenes (group A strep). Suppuration is more likely to be present with Staph aureus.
4. Complete surgical excision of the node is required to avoid development of a draining fistula.
5. Nontuberculous mycobacteria and cat scratch disease are common. EBV, CMV, toxoplasmosis, histoplasmosis, HIV are other infectious etiologies. Malignant diseases such as leukemia, lymphoma and solid tumors such as neuroblastoma, rhabdomyosarcoma and nasopharyngeal carcinoma also need to be considered.