Rosen & Barkin's 5-Minute Emergency Medicine Consult (147 page)

• Enlarged, tender cervical lymph node
  
• Usually unilateral and solitary
  
• Warmth and erythema of overlying skin
  
• Early in course, node is firm but may become fluctuant later
  
• With or without fever
  
• Malaise
  
• Irritability in infants and children
  
• Usually a concurrent head and neck infection:
  
  • Pharyngitis, tonsillitis, peritonsillar abscess
    
  • Otitis media, otitis externa
    
  • Dental infection
    
  • Impetigo, scalp infection
    

• Time of onset of symptoms
  
• Associated symptoms: Fever, weight loss, rash
  
• Exposures/travel history
  
• Comorbidities/birth history for infants
  

Complete evaluation of head and neck with attention to airway and patient’s clinical appearance

• Cervical adenitis is a clinical diagnosis
  
• Identify primary source of infection in head and neck area (e.g., otitis media, tonsillitis)
  
• If no primary inflammatory source of infection in head and neck:
  
  • Address possible TB exposure with PPD
    
  • Look for signs of systemic disease and viral illness
    

• Unnecessary if a treatable primary source of infection confirmed
  
• Blood cultures for toxic-appearing patients
  
• Sepsis workup in neonates
  
• If cause unclear, the following lab tests may help to discern a nonbacterial cause (see “Differential Diagnosis”):
  
  • Leukocyte count with differential
    
  • Monospot
    
  • Throat cultures
    
  • Antibody titers (Epstein–Barr virus, CMV, toxoplasmosis)
    

• CXR study, lateral neck, or Panorex:
  
  • Helpful if source of infection unclear or to rule out a deep space infection
    
  • Chest radiograph study to screen for TB
    
• CT or MRI of neck:
  
  • Helpful to exclude deep space infections or delineating embryonic developmental masses
    
• US:
  
  • Can differentiate cystic from solid structures, but other findings nonspecific
    
  • Can identify deep-cavity abscess if not palpable on exam
    
• Excisional biopsy
  

• Needle aspiration:
  
  • All fluctuant nodes should be aspirated
    
  • Send for Gram stain and acid-fast stains, aerobic and anaerobic cultures, mycobacteria, and fungi
    
  • If any suspicion of tuberculous lymphadenitis, the node should not be aspirated owing to risk for sinus development and chronic drainage
    
• Intradermal skin testing:
  
  • Mycobacteria, catscratch disease
    

• Lymphadenopathy (inflammation of node but no bacterial infection) can be a sign of many systemic diseases; usually these nodes are multiple and bilateral
  
• Viral infections are a common cause:
  
  • Respiratory viruses (adenoviruses, rhinoviruses, enteroviruses)
    
  • Epstein–Barr virus, herpes simplex virus, varicella-zoster virus, CMV
    
  • Mumps, rubella, rubeola
    
• Specific pediatric diseases with cervical adenitis in their diagnostic criteria:
  
  • Kawasaki disease
    
  • Kikuchi disease
    
  • Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis known by mnemonic PFAPA (seen in preschool-aged children)
    
• Toxoplasmosis
  
• Congenital cysts:
  
  • Brachial cleft cysts, thyroglossal duct cysts, cystic hygromas
    
• Malignancies:
  
  • Leukemia, lymphoma, rhabdomyosarcoma, thyroid carcinoma
    
  • Rare cause of a nonspecific lump in children (<2% overall)
    
• Other systemic diseases:
  
  • Lupus, sarcoidosis
    

TREATMENT

• Oxygen, monitor airway for any signs of compromise
  
• Universal precautions
  

• Treatment directed toward the primary source of infection in the head and neck:
  
  • If unsure of cause, treat for group A Streptococcus and
    S. aureus
    
  • Consider MRSA if symptoms not improving on standard antibiotic therapy
    
• Aspirate all fluctuant nodes
  
• Many oral antibiotics are effective:
  
  • Cephalexin
    
  • Cefadroxil
    
  • Amoxicillin/clavulanic acid
    
• Patients with suspected dental, periodontal, or anaerobic causes of illness:
  
  • Clindamycin
    
  • Amoxicillin/clavulanic acid
    
• CA-MRSA:
  
  • Clindamycin (many isolates are now resistant)
    
  • Bactrim
    
  • Vancomycin or Linezolid if toxic and requiring inpatient care
    
• Treatment should be for at least 10 days, even if symptoms resolve sooner
  
• Warm, moist compresses
  
• Analgesics, as needed
  

• Cefadroxil: 500 mg (peds: 30 mg/kg/24 h) PO q12h
  
• Cephalexin: 250–500 mg (peds: 25–50 mg/kg/24 h) PO q6h
  
• Amoxicillin/clavulanic acid: 250–500 mg (peds: 20–40 mg/kg/24 h) PO q8h
  
• Clindamycin: 300 mg (peds: 8–25 mg/kg/24 h) PO q6h
  
• TMP-SMX (Bactrim): DS (160/800) 2 tabs PO BID (peds: 40 mg/200 mg/10 kg/PO BID)
  

• Cefazolin: 1–2 g (peds: 25–50 mg/kg/24 h) IV q8h
  
• Nafcillin: 1–2 g (peds: 50–200 mg/kg/24 h) IV q4–6h
  
• Clindamycin: 600–900 mg (peds: 20–40 mg/kg/24 h) IV q8h
  
• Ampicillin–sulbactam: 1.5–3 g (peds: 200 mg/kg/d) q6h
  
• Vancomycin: 10--15 mg/kg IV Q12h (peds: 40--60 mg/kg/d div q8h)
  
• Linezolid (alternative to Vancomycin): 600 mg IV BID for children >12 or 30 mg/kg/8 h with max. dose of 1,200 mg for children <12 yr
  

FOLLOW-UP

• Neonates
  
• Airway compromise
  
• Patient appears ill
  
• Immunocompromised
  
• Inability to take PO
  
• Not improving on oral antibiotics
  

• Most patients can be discharged on PO antibiotics
  
• Close follow-up with a recheck in 2–3 days
  
• Ability to take PO antibiotics and fluids
  
• Return to the ED if:
  
  • Symptoms worsen
    
  • Abscess develops
    
  • Voice changes
    
  • Dyspnea develops
    
  • Systemic symptoms develop
    

Clinical exam concerning for malignancy or congenital abnormality (brachial cleft/thyroglossal duct cyst)

• Mandatory recheck in 48 hr to ensure improvement
  
• Referral to dentist or ENT depending on source of infection
  

• Cervical adenitis is a clinical diagnosis
  
• Unilateral warm, tender, swollen, erythematous lymph node
  
• Most common bacteria responsible for infection are group A
  Strep
  and
  S. aureus
  .
  
• Consider group B Strep in infants and MRSA for infections not improving on standard antibiotics
  
• Disposition should be influenced by patient’s clinical status
  

• Hay WW, Levin MJ Jr, Deterding R, et al.
  CURRENT Diagnosis & Treatment: Pediatrics
  . 21st ed. McGraw-Hill; 2012:503.
  
• Healy CM. Diagnostic approach to and initial treatment of cervical lymphadenitis in children.
  UpToDate.com/online
  
• Healy CM, Baker CJ. Cervical lymphadenitis. In: Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL, eds.
  Textbook of Pediatric Infectious Diseases
  . 6th ed. Philadelphia, PA: Saunders; 2009:185.
  
• Swanson D. Etiology and clinical manifestations of cervical lymphadenitis in children.
  UpToDate.com/online
  

See Also (Topic, Algorithm, Electronic Media Element)

• Kawasaki Disease
  
• Lymphadenitis
  

CODES

683 Acute lymphadenitis

BASICS