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Cervical lymphadenitis: Etiology, diagnosis, and management

Cervical lymphadenitis: Etiology, diagnosis, and management Cervical Lymphadenitis: Etiology, Diagnosis, and Management Alexander K.C. Leung , MBBS, FRCPC, FRCP(UK&Irel), FRCPCH, and H. Dele Davies , MD, MS, MHCM, FRCPC Corresponding author differential diagnosis, clinical and laboratory evaluation, Alexander K.C. Leung, MBBS, FRCPC, FRCP(UK&Irel), FRCPCH and management of children with cervical lymphadenitis. Department of Pediatrics, University of Calgary, Alberta Children’s Hospital, Room 200, 233 16th Avenue NW, Calgary, Alberta, Canada T2M 0H5. Pathophysiology E-mail: aleung@ucalgary.ca The superfi cial cervical lymph nodes lie on top of the ster- Current Infectious Disease Reports 2009, 11: 18 3 – 189 nomastoid muscle and include the anterior group, which Current Medicine Group LLC ISSN 1523-3847 Copyright © 2009 by Current Medicine Group LLC lies along the anterior jugular vein, and the posterior group, which lies along the external jugular vein [ 4••]. The deep cervical lymph nodes lie deep to the sternomas- Cervical lymphadenopathy is a common problem in toid muscle along the internal jugular vein and are divided children. The condition most commonly represents into superior and inferior groups. The superior deep nodes a transient response to a benign local or general- lie below the angle of the mandible, whereas the inferior ized infection. Acute bilateral cervical lymphadenitis deep nodes lie at the base of the neck. is usually caused by a viral upper respiratory tract The superfi cial cervical lymph nodes receive afferents infection or streptococcal pharyngitis. Acute unilat- from the mastoid, tissues of the neck, and the parotid (preau- eral cervical lymphadenitis is caused by streptococcal ricular) and submaxillary nodes [4• •]. T he efferent drainage or staphylococcal infection in 40% to 80% of cases. terminates in the superior deep cervical lymph nodes [ 4••]. Common causes of subacute or chronic lymphad- The superior deep cervical nodes drain the palatine tonsils enitis include cat-scratch disease and mycobacterial and the submental nodes. The lower deep cervical nodes infection. Generalized lymphadenopathy is often drain the larynx, trachea, thyroid, and esophagus. caused by a viral infection, and less frequently by Offending organisms usually fi rst infect the upper respi- malignancies, collagen vascular diseases, and medi- ratory tract, anterior nares, oral cavity, or skin in the head cations. Laboratory tests are not necessary in most and neck area before spreading to the cervical lymph nodes. children with cervical lymphadenopathy. Most cases The lymphatic system in the cervical area serves as a bar- of cervical lymphadenitis are self-limited and require rier to prevent further invasion and dissemination of these no treatment. The treatment of acute bacterial cervi- organisms. The nodal enlargement occurs as a result of cal lymphadenitis without a known primary source proliferation of cells intrinsic to the node (eg, lymphocytes, should provide adequate coverage for both Staphylo- plasma cells, monocytes, and histiocytes) or by infi ltration of coccus aureus a nd Streptococcus pyogenes . cells extrinsic to the node (eg, neutrophils). Because infections involving the head and neck areas are common in children, cervical lymphadenitis is common in this age group [ 5 ]. Introduction Enlarged cervical lymph nodes are common in children [ 1 ]. About 38% to 45% of otherwise normal children have pal- Etiology pable cervical lymph nodes [ 2 ]. Cervical lymphadenopathy Causes of cervical lymphadenopathy are listed in Table 1 is usually defi ned as cervical lymph nodal tissue measuring [ 1 ]. The most common cause is reactive hyperplasia result- more than 1 cm in diameter [ 3 ]. Cervical lymphadenopathy ing from an infectious process, typically a viral upper most commonly represents a transient reactive response to respiratory tract infection [ 6 ]. Upper respiratory tract a benign local or generalized infection, but occasionally it infection might be caused by rhinovirus, parainfl uenza might herald the presence of a more serious disorder (eg, virus, infl uenza virus, respiratory syncytial virus, coro- malignancy). Lymphadenitis specifi cally refers to lymph- navirus, adenovirus, or reovirus [ 1 , 4••]. O ther viruses adenopathies that are caused by infl ammatory processes associated with cervical lymphadenopathy include Epstein- [ 4••] . This article reviews the pathophysiology, etiology, Barr virus (EBV), cytomegalovirus (CMV), rubella, rubeola, 184 Upper Respiratory, Head, and Neck Infections Table 1. Causes of cervical lymphadenopathy henselae (cat-scratch disease), nontuberculosis mycobacteria (eg, Mycobacterium avium-intracellulare, Mycobacterium A. Infection scrofulaceum ), and Mycobacterium tuberculosis (“ scrofula”) 1. Viral are important causes of subacute or chronic cervical lymph- a. Viruses causing upper respiratory infection (eg, rhino- adenopathy [8 ]. Chronic posterior cervical lymphadenitis is virus, parainfl uenza virus, infl uenza virus, respiratory the most common form of acquired toxoplasmosis and is the syncytial virus, coronavirus, adenovirus, reovirus) sole presenting symptom in 50% of cases [ 1 ]. b. Epstein-Barr virus More than 25% of malignant tumors in children occur c. Cytomegalovirus d. Rubella in the head and neck, and the cervical lymph nodes are e. Rubeola the most common site [ 1 ]. During the fi rst 6 years of life, f. Varicella-zoster virus neuroblastoma and leukemia are the most common tumors g. Herpes simplex virus associated with cervical lymphadenopathy, followed by h. Coxsackievirus rhabdomyosarcoma and non-Hodgkin’s lymphoma [ 1 ]. After i. HIV 6 years of age, Hodgkin’s lymphoma is the most common 2. Bacterial tumor associated with cervical lymphadenopathy, followed a. Staphylococcus aureus by non-Hodgkin’s lymphoma and rhabdomyosarcoma. b. Streptococcus pyogenes The presence of cervical lymphadenopathy is an c. Haemophilus infl uenzae important diagnostic feature for Kawasaki disease. The d. Anaerobes other features include fever lasting 5 days or more, bilat- e. Corynebacterium diphtheriae f. Bartonella henselae eral bulbar conjunctival injection, infl ammatory changes g. Mycobacterium tuberculosis, Mycobacterium in the mucosa of the oropharynx, erythema or edema of avium-intracellulare, Mycobacterium scrofulaceum the peripheral extremities, and polymorphous rash. i. Nocardia brasiliensis Generalized lymphadenopathy might be a feature of j. Pasteurella multocida systemic-onset juvenile rheumatoid arthritis, systemic k. Treponema pallidum lupus erythematosus, or serum sickness. Certain drugs— 3. Protozoal notably phenytoin, carbamazepine, hydralazine, and a. Toxoplasma gondii isoniazid—might cause generalized lymphadenopathy. Cervi- b. Leishmania species cal lymphadenopathy has been reported after immunization 4. Fungal with diphtheria-pertussis-tetanus, poliomyelitis, or typhoid a. Candida albicans fever vaccine [ 1 ]. Rosai-Dorfman disease is a benign form b. Histoplasma capsulatum of histiocytosis characterized by generalized proliferation of c. Blastomyces dermatitides sinusoidal histiocytes. The disease usually manifests in the d. Coccidioides immitis fi rst decade of life with massive and painless cervical lymph- e. Aspergillus fumigatus adenopathy, often accompanied by fever, malaise, weight loss, B. Malignancies neutrophilic leukocytosis, elevated erythrocyte sedimentation 1. Neuroblastoma rate, and polyclonal hypergammaglobulinemia. Kikuchi-Fuji- 2. Leukemia moto disease (histocytic necrotizing lymphadenitis) is a benign 3. Lymphoma cause of lymph node enlargement, usually in the posterior 4. Rhabdomyosarcoma cervical triangle [ 9 ]. The condition primarily affects young C. Miscellaneous females. Fever, nausea, weight loss, night sweats, arthralgia, 1. Kawasaki disease myalgia, or hepatosplenomegaly might be present. The etiol- 2. Collagen vascular diseases ogy of Kikuchi-Fujimoto disease is unknown, but a viral cause 3. Serum sickness has been implicated [ 9 ]. Classical pathologic fi ndings include 4. Drugs patchy areas of necrosis in the cortical and paracortical areas 5. Postvaccination of the enlarged lymph nodes and a histiocytic infi ltrate [9 ]. 6. Rosai-Dorfman disease 7. Kikuchi-Fujimoto disease (Modifi ed from Leung and Robson [5].) Differential Diagnosis The differential diagnosis of neck masses is different in children due to a higher incidence of infectious diseases varicella-zoster virus, herpes simplex virus (HSV), coxsacki- evirus, and HIV. Bacterial cervical lymphadenitis is usually and congenital anomalies and the relative rarity of malig- caused by Streptococcus pyogenes (group A β -hemolytic nancies in the pediatric age group. Cervical masses in streptococci) or Staphylococcus aureus [ 7 ]. Anaerobic bac- children might be mistaken for enlarged cervical lymph teria can cause cervical lymphadenitis, usually in association nodes. In general, congenital lesions are painless and are with dental caries and periodontal disease. Group B strepto- present at birth or identifi ed soon thereafter [ 10 ]. Clinical cocci and Haemophilus infl uenzae t ype b are less frequent features that may help distinguish the various conditions causal organisms. Diphtheria is a rare cause. Bartonella from cervical lymphadenopathy are as follows. Cervical Lymphadenitis: Etiology, Diagnosis, and Management Leung and Davies 185 I I Mumps History The swelling of mumps parotitis crosses the angle of the Age of the child jaw. On the other hand, cervical lymph nodes are usually Some organisms have a predilection for specifi c age below the mandible [ 1 ]. groups. S. aureus and group B streptococci have a pre- dilection for neonates; S. aureus, g roup B streptococci, Thyroglossal cyst and Kawasaki disease for infants; viral agents, S. aureus, A thyroglossal cyst is a mass that can be distinguished by group A β -hemolytic streptococci, and atypical mycobac- its midline location between the hyoid bone and supra- teria for children from 1 to 4 years of age; and anaerobic sternal notch and the upward movement of the cyst when bacteria, toxoplasmosis, cat-scratch disease, and tubercu- the child swallows or sticks out his or her tongue. losis for children from 5 to 15 years of age. Most children with cervical lymphadenitis are 1 to 4 years of age. The Branchial cleft cyst prevalence of various childhood neoplasms changes with A branchial cleft cyst is a smooth and fl uctuant mass located age. In general, lymphadenopathy secondary to neoplasia along the lower anterior border of the sternomastoid muscle. increases in the adolescent age group [4• •]. Laterality and chronicity Sternocleidomastoid tumor Acute bilateral cervical lymphadenitis is usually caused A sternocleidomastoid tumor is a hard, spindle-shaped mass in the sternocleidomastoid muscle possibly result- by a viral upper respiratory tract infection or pharyn- ing from perinatal hemorrhage into the muscle with gitis due to S. pyogenes [ 1 , 11 ]. Acute unilateral cervical subsequent healing by fi brosis [ 1 ]. The tumor can be lymphadenitis is caused by S. pyogenes or S. aureus moved from side to side but not upward or downward. in 40% to 80% of cases [ 6 , 12 ]. The classical cervical Torticollis is usually present. lymphadenopathy in Kawasaki disease is usually acute and unilateral. Typically, acute suppurative lymphadeni- Cervical ribs tis is caused by S. aureus or S. pyogenes [ 13]. S ubacute Cervical ribs are orthopedic anomalies that are usually or chronic cervical lymphadenitis is often caused by bilateral, hard, and immovable. Diagnosis is established B. henselae , Toxoplasma gondii , EBV, CMV, nontuber- with a radiograph of the neck. culosis mycobacteria, and M. tuberculosis [ 1 , 11 ]. Less common causes include syphilis, Nocardia brasiliensis, Cystic hygroma and fungal infection. A cystic hygroma is a multiloculated, endothelial-lined cyst that is diffuse, soft, and compressible, contains lym- Associated symptoms phatic fl uid, and typically transilluminates brilliantly. Fever, sore throat, and cough suggest an upper respira- tory tract infection. Fever, night sweats, and weight loss Hemangioma suggest lymphoma or tuberculosis. Recurrent cough and A hemangioma is a congenital vascular anomaly that hemoptysis are indicative of tuberculosis. Unexplained often is present at birth or appears shortly thereafter. The fever, fatigue, and arthralgia raise the possibility of col- mass is usually red or bluish. lagen vascular disease or serum sickness. Concurrent illness and past health Laryngocele A laryngocele is a soft, cystic, compressible mass that Preceding tonsillitis suggests streptococcal infection. Recent extends out of the larynx and through the thyrohy- facial or neck abrasion or infection suggests staphylococ- oid membrane and becomes larger with the Valsalva cal infection. Periodontal disease might indicate infections maneuver. There might be associated stridor or hoarse- caused by anaerobic organisms. A history of cat-scratch ness. A radiograph of the neck might show an air fl uid raises the possibility of B. henselae infection. A history of level in the mass. dog bite or scratch suggests specifi c causative agents such as Pasteurella multocida an d S. aureus. L ymphadenopathy Dermoid cyst resulting from CMV, EBV, or HIV might follow a blood transfusion. The immunization status of the child should A dermoid cyst is a midline cyst that contains solid and cystic components. It seldom transilluminates as bril- be determined. Immunization-related lymphadenopathy liantly as a cystic hygroma. A radiograph might show that might follow diphtheria-pertussis-tetanus, poliomyelitis, or it contains calcifi cations. typhoid fever vaccination. Drug use The response of cervical lymphadenopathy to specifi c Clinical Evaluation antimicrobial therapies might help to confi rm or exclude A detailed history and a thorough physical examination are essential in the evaluation of the child with cervical a diagnosis. Lymphadenopathy might follow the use of lymphadenopathy. medications such as phenytoin and isoniazid. 186 Upper Respiratory, Head, and Neck Infections Table 2. Differentiation of nontuberculosis mycobacterial and Mycobacterium tuberculosis cervical lymphadenitis Clinical characteristics Non tuberculosis mycobacteria M. tuberculosis Age 1 to 4 y Al l ages (most > 5 y) Race Predominantly white Predominantly black or Hispanic Exposure to tuberculosis Ab sent Present Constitutional symptoms Absent Present Cervical lymphadenitis Usually solitary, in submandibular area Usually multiple, bilateral, in posterior cervical or supraclavicular area Sinus tract formation Approximately 10% Rare Chest radiograph Norm al (97%) A bnormal (20%–70%) Residence Ru ral Urban PPD > 15 mm of induration* Un common Usual Response to antimycobacterial drugs No Yes *PPD refers to 5 tuberculin units (5 TU) intradermal skin test. Exposure to infection pathogen is present, the nodes can be either unilateral or Exposure to a person with an upper respiratory tract bilateral, are usually tender, might be fl uctuant, and are infection, streptococcal pharyngitis, or tuberculosis sug- not fi xed. The presence of erythema and warmth sug- gests the corresponding disease. A history of recent travel gests an acute pyogenic process, and fl uctuance suggests should be sought. abscess formation. A “cold” abscess is characteristic of infection caused by mycobacteria, fungi, or B. henselae. Physical examination In patients with tuberculosis, the nodes might be matted General or fl uctuant, and the overlying skin might be erythema- Malnutrition or poor growth suggests chronic disease tous but is typically not warm [ 8 ]. Clinical features that such as tuberculosis, malignancy, or immunodefi ciency. help differentiate nontuberculosis mycobacterial cervical lymphadenitis from M. tuberculosis cervical lymphad- Characteristics of the lymph tissue enitis are summarized in Table 2 [ 3 , 15 ]. Approximately All accessible node-bearing areas should be examined to 50% of patients with lymphadenitis caused by nontu- determine whether the lymphadenopathy is generalized. berculosis mycobacteria develop fl uctuance of the lymph The nodes should be measured for future comparison [ 1 ]. node and spontaneous drainage; sinus tract formation Fluctuation in size of the nodes suggests a reactive pro- occurs in 10% of affected patients [ 4••, 16••]. I n lymph- cess, whereas relentless increase in size indicates a serious adenopathy resulting from malignancy, signs of acute pathology [ 1 , 14]. T enderness, erythema, warmth, mobil- infl ammation are absent, and the lymph nodes are hard ity, fl uctuance, and consistency should be assessed. and often fi xed to the underlying tissue. The location of involved lymph nodes often gives clues to the entry site of the organism and should prompt Associated signs a detailed examination of that site. Submandibular and A thorough examination of the ears, eyes, nose, oral submental lymphadenopathy is most often caused by cavity, and throat is necessary. Acute viral cervical lymph- an oral or dental infection, although this feature may adenitis is variably associated with fever, rhinorrhea, also be seen in cat-scratch disease and non-Hodgkin’s conjunctivitis, pharyngitis, and sinus congestion [ 4••]. A lymphoma. Acute posterior cervical lymphadenitis is beefy red throat, exudate on the tonsils, petechiae on the classically seen in persons with rubella and infectious hard palate, and a strawberry tongue suggest infection mononucleosis [1 , 11] . Supraclavicular or posterior caused by S. pyogenes [ 1 ]. Unilateral facial or submandib- cervical lymphadenopathy carries a much higher risk ular swelling, erythema, tenderness, fever, and irritability for malignancy than does anterior cervical lymphade- in an infant suggest group B streptococcal infection [ 13]. nopathy. Cervical lymphadenopathy associated with Diphtheria is associated with edema of the soft tissues of generalized lymphadenopathy is often caused by a viral the neck, often described as “bull-neck” appearance. The infection. Malignancies (eg, leukemia or lymphoma), col- presence of gingivostomatitis suggests infection with HSV, lagen vascular diseases (eg, juvenile rheumatoid arthritis whereas herpangina suggests infection with coxsackievi- or systemic lupus erythematosus), and some medications rus [ 11 ]. Rash and hepatosplenomegaly suggest EBV or are also associated with generalized lymphadenopathy. CMV infection [4• •] . The presence of pharyngitis, macu- In lymphadenopathy resulting from a viral infec- lopapular rash, and splenomegaly suggest EBV infection tion, the nodes are usually bilateral and soft and are [ 17]. C onjunctivitis and Koplik spots are characteristics of not fi xed to the underlying structure. When a bacterial rubeola. The presence of pallor, petechiae, bruises, sternal Cervical Lymphadenitis: Etiology, Diagnosis, and Management Leung and Davies 187 I I tenderness, and hepatosplenomegaly suggests leukemia. part of the lymph node for biopsy [ 22 ]. The technique Prolonged fever, conjunctival infection, oropharyngeal also allows detection of small lymphadenopathies. mucous membrane infl ammation, peripheral edema or Fine-needle aspiration and culture of a lymph node erythema, and a polymorphous rash are consistent with is a safe and reliable procedure to isolate the causative Kawasaki disease. organism and to determine the appropriate antibiotic when bacterial infection is the cause [ 23 ]. Failure to improve or worsening of the patient’s condition while on Diagnostic Evaluation antibiotic treatment is an indication for fi ne-needle aspi- Laboratory tests are not necessary in most children with cer- ration and culture [4• •]. A ll aspirated material should be vical lymphadenopathy. A complete blood cell count might sent for Gram and acid-fast stain and cultures for aerobic help to suggest a bacterial lymphadenitis, which is often and anaerobic bacteria, mycobacteria, and fungi [ 4••, 24 ]. accompanied by leukocytosis with a shift to the left and If the Gram stain is positive, only bacterial cultures are toxic granulations. Atypical lymphocytosis is prominent in mandatory. Polymerase chain reaction testing is a fast and infectious mononucleosis [ 17] . Pancytopenia, leukocytosis, useful technique for the demonstration of mycobacterial or the presence of blast cells suggests leukemia. The eryth- DNA fragments [ 15 ]. rocyte sedimentation rate and C-reactive protein are usually An excisional biopsy with microscopic examination signifi cantly elevated in persons with bacterial lymphadeni- of the lymph node might be necessary to establish the tis. Blood culture should be obtained if the child appears diagnosis if symptoms or signs of malignancy are present toxic. A rapid streptococcal antigen test or a throat culture or if the lymphadenopathy persists or enlarges in spite of might be useful to confi rm a streptococcal infection [18 ]. appropriate antibiotic therapy and the diagnosis remains An electrocardiogram and echocardiogram are indicated if in doubt [ 5 ]. The biopsy should be performed on the larg- Kawasaki disease is suspected. est and fi rmest node that is palpable, and the node should Skin tests for tuberculosis should be performed in patients be removed intact with the capsule [1 , 10 ]. with subacute or chronic adenitis. Chest radiography should be performed if the tuberculin skin test is positive or if an underlying chest pathology is suspected, especially in the Management child with chronic or generalized lymphadenopathy. Sero- Treatment of cervical lymphadenopathy depends on the logic tests for B. henselae, EBV, CMV, brucellosis, syphilis, underlying cause. Most cases are self-limited and require and toxoplasmosis should be performed when indicated. If no treatment other than observation. This applies espe- the serology is positive, the diagnosis can be established and cially to small, soft, and mobile lymph nodes associated excision biopsy can be avoided [19 • ]. with upper respiratory infections, which are often viral in Ultrasonography (US) is the most useful diagnostic origin. These children require follow-up in 2 to 4 weeks. imaging modality in the assessment of cervical lymph The treatment of acute bacterial cervical lymphadenitis nodes. US may help to differentiate a solid mass from a without a known primary infectious source should provide cystic mass and to establish the presence and extent of adequate coverage for both S. aureus and S. pyogenes , suppuration or infi ltration. High-resolution and color US pending the results of the culture and sensitivity tests [ 5 ]. can provide detailed information on the longitudinal and Appropriate oral antibiotics include cloxacillin, cephalexin, transverse diameter, morphology, texture, and vascular- cefprozil, or clindamycin [ 6 ]. Children with cervical lymph- ity of the lymph node [ 4••, 14]. A l ong-to-short axis ratio adenopathy and periodontal or dental disease should be greater than 2 suggests benignity, whereas a ratio less treated with clindamycin or a combination of amoxicillin than 2 suggests malignancy [ 14 ]. In lymphadenitis caused and clavulanic acid, which provide coverage for anaerobic by an infl ammatory process, the intranodal vasculature is oral fl ora [ 6 , 25 ]. Referral to a pediatric dentist for treat- dilated, whereas in lymphadenopathy secondary to neo- ment of the underlying periodontal or dental disease is plastic infi ltration, the intranodal vasculature is usually warranted. Antimicrobial therapy may have to be modifi ed distorted. Absence of an echogenic hilus and overall lymph once a causative agent is identifi ed, depending on the clini- node hyperechogenicity are suggestive of malignancy cal response of the existing treatment. Because of its proven [ 20• ]. US can also be used to guide core-needle biopsy effi cacy, safety, and narrow spectrum of antimicrobial for diagnosing the cause of cervical lymphadenopathy activity, penicillin remains the drug of choice for adenitis in patients without known malignancy and may obviate caused by S. pyogenes , except in patients allergic to penicil- unnecessary excisional biopsy [21 •] . Advantages of US lin [ 7 ]. Methicillin-resistant S. aureus i s resistant to many include cost-effectiveness, noninvasiveness, and absence kinds of antibiotics. Currently, vancomycin is the drug of radiation hazard. A potential drawback is its lack of of choice for complicated cases, although trimethoprim- absolute specifi city and sensitivity in ruling out neoplastic sulfamethoxazole or clindamycin is often adequate for processes as the cause of lymphadenopathy [4• •]. uncomplicated outpatient management [26 ]. Diffusion-weighted MRI with apparent diffusion coef- In most patients, symptomatic improvement should fi cient mapping can be helpful to differentiate malignant be noted after 48 to 72 hours of therapy. Fine-needle from benign lymph nodes and delineate the solid, viable aspiration and culture should be considered if there is no 188 Upper Respiratory, Head, and Neck Infections clinical improvement or if the patient’s condition dete- Acknowledgment riorates. If the lymph nodes become fl uctuant, incision This article was published in part by Leung and Robson and drainage should be performed. Failure of regres- [ 1 ] in the Journal of Pediatric Health Care, w ith permis- sion of lymphadenopathy after 4 to 6 weeks might be an sion from Elsevier. It has been signifi cantly updated for indication for a diagnostic biopsy [ 12 ]. Indications for the current article. early excision biopsy for histology include lymph node in the supraclavicular area, lymph node larger than 3 cm, lymph nodes in children with a history of malignancy, Disclosure and clinical fi ndings of fever, night sweats, weight loss, No potential confl icts of interest relevant to this article and hepatosplenomegaly [ 19• ]. were reported. Toxic or immunocompromised children and those who do not tolerate, will not take, or fail to respond to oral medi- cation should be treated with intravenous nafcillin, cefazolin, References and Recommended Reading or clindamycin [6 ]. 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The treatment of acute bacterial cervical lymphadenitis This multicenter, randomized, controlled trial compared surgical excision versus antibiotic treatment for nontuberculous myocobac- without a known primary infectious source should provide terial cervicofacial lymphadenitis in children. adequate coverage for both S. aureus and S. pyogenes . Cervical Lymphadenitis: Etiology, Diagnosis, and Management Leung and Davies 189 I I 17. Leung AK, Pinto-Rojas A: Infectious mononucleosis. 22. Abdel Razek AA, Soliman NY, Elkhamary MK, Ta wfi k Consultant 2000, 40: 134 – 136. A: Role of diffusion-weighted MR imaging in cervical lymphadenopathy. Eur Radiol 2 006, 16: 14 68– 1477. 18. Leung AK, Newman R, Kumar A, et al.: Rapid antigen detec- tion testing in diagnosing group A b-hemolytic streptococcal 23. Buchino JJ, Jones VF: F ine needle aspiration in the evalu- pharyngitis. Expert Rev Mol Diagn 2006, 6: 761– 76 6. ation of children with lymphadenopathy. 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Cervical lymphadenitis: Etiology, diagnosis, and management

Current Infectious Disease Reports , Volume 11 (3) – Apr 18, 2009

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Pubmed Central
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© Current Medicine Group, LLC 2009
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1523-3847
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1534-3146
DOI
10.1007/s11908-009-0028-0
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Cervical Lymphadenitis: Etiology, Diagnosis, and Management Alexander K.C. Leung , MBBS, FRCPC, FRCP(UK&Irel), FRCPCH, and H. Dele Davies , MD, MS, MHCM, FRCPC Corresponding author differential diagnosis, clinical and laboratory evaluation, Alexander K.C. Leung, MBBS, FRCPC, FRCP(UK&Irel), FRCPCH and management of children with cervical lymphadenitis. Department of Pediatrics, University of Calgary, Alberta Children’s Hospital, Room 200, 233 16th Avenue NW, Calgary, Alberta, Canada T2M 0H5. Pathophysiology E-mail: aleung@ucalgary.ca The superfi cial cervical lymph nodes lie on top of the ster- Current Infectious Disease Reports 2009, 11: 18 3 – 189 nomastoid muscle and include the anterior group, which Current Medicine Group LLC ISSN 1523-3847 Copyright © 2009 by Current Medicine Group LLC lies along the anterior jugular vein, and the posterior group, which lies along the external jugular vein [ 4••]. The deep cervical lymph nodes lie deep to the sternomas- Cervical lymphadenopathy is a common problem in toid muscle along the internal jugular vein and are divided children. The condition most commonly represents into superior and inferior groups. The superior deep nodes a transient response to a benign local or general- lie below the angle of the mandible, whereas the inferior ized infection. Acute bilateral cervical lymphadenitis deep nodes lie at the base of the neck. is usually caused by a viral upper respiratory tract The superfi cial cervical lymph nodes receive afferents infection or streptococcal pharyngitis. Acute unilat- from the mastoid, tissues of the neck, and the parotid (preau- eral cervical lymphadenitis is caused by streptococcal ricular) and submaxillary nodes [4• •]. T he efferent drainage or staphylococcal infection in 40% to 80% of cases. terminates in the superior deep cervical lymph nodes [ 4••]. Common causes of subacute or chronic lymphad- The superior deep cervical nodes drain the palatine tonsils enitis include cat-scratch disease and mycobacterial and the submental nodes. The lower deep cervical nodes infection. Generalized lymphadenopathy is often drain the larynx, trachea, thyroid, and esophagus. caused by a viral infection, and less frequently by Offending organisms usually fi rst infect the upper respi- malignancies, collagen vascular diseases, and medi- ratory tract, anterior nares, oral cavity, or skin in the head cations. Laboratory tests are not necessary in most and neck area before spreading to the cervical lymph nodes. children with cervical lymphadenopathy. Most cases The lymphatic system in the cervical area serves as a bar- of cervical lymphadenitis are self-limited and require rier to prevent further invasion and dissemination of these no treatment. The treatment of acute bacterial cervi- organisms. The nodal enlargement occurs as a result of cal lymphadenitis without a known primary source proliferation of cells intrinsic to the node (eg, lymphocytes, should provide adequate coverage for both Staphylo- plasma cells, monocytes, and histiocytes) or by infi ltration of coccus aureus a nd Streptococcus pyogenes . cells extrinsic to the node (eg, neutrophils). Because infections involving the head and neck areas are common in children, cervical lymphadenitis is common in this age group [ 5 ]. Introduction Enlarged cervical lymph nodes are common in children [ 1 ]. About 38% to 45% of otherwise normal children have pal- Etiology pable cervical lymph nodes [ 2 ]. Cervical lymphadenopathy Causes of cervical lymphadenopathy are listed in Table 1 is usually defi ned as cervical lymph nodal tissue measuring [ 1 ]. The most common cause is reactive hyperplasia result- more than 1 cm in diameter [ 3 ]. Cervical lymphadenopathy ing from an infectious process, typically a viral upper most commonly represents a transient reactive response to respiratory tract infection [ 6 ]. Upper respiratory tract a benign local or generalized infection, but occasionally it infection might be caused by rhinovirus, parainfl uenza might herald the presence of a more serious disorder (eg, virus, infl uenza virus, respiratory syncytial virus, coro- malignancy). Lymphadenitis specifi cally refers to lymph- navirus, adenovirus, or reovirus [ 1 , 4••]. O ther viruses adenopathies that are caused by infl ammatory processes associated with cervical lymphadenopathy include Epstein- [ 4••] . This article reviews the pathophysiology, etiology, Barr virus (EBV), cytomegalovirus (CMV), rubella, rubeola, 184 Upper Respiratory, Head, and Neck Infections Table 1. Causes of cervical lymphadenopathy henselae (cat-scratch disease), nontuberculosis mycobacteria (eg, Mycobacterium avium-intracellulare, Mycobacterium A. Infection scrofulaceum ), and Mycobacterium tuberculosis (“ scrofula”) 1. Viral are important causes of subacute or chronic cervical lymph- a. Viruses causing upper respiratory infection (eg, rhino- adenopathy [8 ]. Chronic posterior cervical lymphadenitis is virus, parainfl uenza virus, infl uenza virus, respiratory the most common form of acquired toxoplasmosis and is the syncytial virus, coronavirus, adenovirus, reovirus) sole presenting symptom in 50% of cases [ 1 ]. b. Epstein-Barr virus More than 25% of malignant tumors in children occur c. Cytomegalovirus d. Rubella in the head and neck, and the cervical lymph nodes are e. Rubeola the most common site [ 1 ]. During the fi rst 6 years of life, f. Varicella-zoster virus neuroblastoma and leukemia are the most common tumors g. Herpes simplex virus associated with cervical lymphadenopathy, followed by h. Coxsackievirus rhabdomyosarcoma and non-Hodgkin’s lymphoma [ 1 ]. After i. HIV 6 years of age, Hodgkin’s lymphoma is the most common 2. Bacterial tumor associated with cervical lymphadenopathy, followed a. Staphylococcus aureus by non-Hodgkin’s lymphoma and rhabdomyosarcoma. b. Streptococcus pyogenes The presence of cervical lymphadenopathy is an c. Haemophilus infl uenzae important diagnostic feature for Kawasaki disease. The d. Anaerobes other features include fever lasting 5 days or more, bilat- e. Corynebacterium diphtheriae f. Bartonella henselae eral bulbar conjunctival injection, infl ammatory changes g. Mycobacterium tuberculosis, Mycobacterium in the mucosa of the oropharynx, erythema or edema of avium-intracellulare, Mycobacterium scrofulaceum the peripheral extremities, and polymorphous rash. i. Nocardia brasiliensis Generalized lymphadenopathy might be a feature of j. Pasteurella multocida systemic-onset juvenile rheumatoid arthritis, systemic k. Treponema pallidum lupus erythematosus, or serum sickness. Certain drugs— 3. Protozoal notably phenytoin, carbamazepine, hydralazine, and a. Toxoplasma gondii isoniazid—might cause generalized lymphadenopathy. Cervi- b. Leishmania species cal lymphadenopathy has been reported after immunization 4. Fungal with diphtheria-pertussis-tetanus, poliomyelitis, or typhoid a. Candida albicans fever vaccine [ 1 ]. Rosai-Dorfman disease is a benign form b. Histoplasma capsulatum of histiocytosis characterized by generalized proliferation of c. Blastomyces dermatitides sinusoidal histiocytes. The disease usually manifests in the d. Coccidioides immitis fi rst decade of life with massive and painless cervical lymph- e. Aspergillus fumigatus adenopathy, often accompanied by fever, malaise, weight loss, B. Malignancies neutrophilic leukocytosis, elevated erythrocyte sedimentation 1. Neuroblastoma rate, and polyclonal hypergammaglobulinemia. Kikuchi-Fuji- 2. Leukemia moto disease (histocytic necrotizing lymphadenitis) is a benign 3. Lymphoma cause of lymph node enlargement, usually in the posterior 4. Rhabdomyosarcoma cervical triangle [ 9 ]. The condition primarily affects young C. Miscellaneous females. Fever, nausea, weight loss, night sweats, arthralgia, 1. Kawasaki disease myalgia, or hepatosplenomegaly might be present. The etiol- 2. Collagen vascular diseases ogy of Kikuchi-Fujimoto disease is unknown, but a viral cause 3. Serum sickness has been implicated [ 9 ]. Classical pathologic fi ndings include 4. Drugs patchy areas of necrosis in the cortical and paracortical areas 5. Postvaccination of the enlarged lymph nodes and a histiocytic infi ltrate [9 ]. 6. Rosai-Dorfman disease 7. Kikuchi-Fujimoto disease (Modifi ed from Leung and Robson [5].) Differential Diagnosis The differential diagnosis of neck masses is different in children due to a higher incidence of infectious diseases varicella-zoster virus, herpes simplex virus (HSV), coxsacki- evirus, and HIV. Bacterial cervical lymphadenitis is usually and congenital anomalies and the relative rarity of malig- caused by Streptococcus pyogenes (group A β -hemolytic nancies in the pediatric age group. Cervical masses in streptococci) or Staphylococcus aureus [ 7 ]. Anaerobic bac- children might be mistaken for enlarged cervical lymph teria can cause cervical lymphadenitis, usually in association nodes. In general, congenital lesions are painless and are with dental caries and periodontal disease. Group B strepto- present at birth or identifi ed soon thereafter [ 10 ]. Clinical cocci and Haemophilus infl uenzae t ype b are less frequent features that may help distinguish the various conditions causal organisms. Diphtheria is a rare cause. Bartonella from cervical lymphadenopathy are as follows. Cervical Lymphadenitis: Etiology, Diagnosis, and Management Leung and Davies 185 I I Mumps History The swelling of mumps parotitis crosses the angle of the Age of the child jaw. On the other hand, cervical lymph nodes are usually Some organisms have a predilection for specifi c age below the mandible [ 1 ]. groups. S. aureus and group B streptococci have a pre- dilection for neonates; S. aureus, g roup B streptococci, Thyroglossal cyst and Kawasaki disease for infants; viral agents, S. aureus, A thyroglossal cyst is a mass that can be distinguished by group A β -hemolytic streptococci, and atypical mycobac- its midline location between the hyoid bone and supra- teria for children from 1 to 4 years of age; and anaerobic sternal notch and the upward movement of the cyst when bacteria, toxoplasmosis, cat-scratch disease, and tubercu- the child swallows or sticks out his or her tongue. losis for children from 5 to 15 years of age. Most children with cervical lymphadenitis are 1 to 4 years of age. The Branchial cleft cyst prevalence of various childhood neoplasms changes with A branchial cleft cyst is a smooth and fl uctuant mass located age. In general, lymphadenopathy secondary to neoplasia along the lower anterior border of the sternomastoid muscle. increases in the adolescent age group [4• •]. Laterality and chronicity Sternocleidomastoid tumor Acute bilateral cervical lymphadenitis is usually caused A sternocleidomastoid tumor is a hard, spindle-shaped mass in the sternocleidomastoid muscle possibly result- by a viral upper respiratory tract infection or pharyn- ing from perinatal hemorrhage into the muscle with gitis due to S. pyogenes [ 1 , 11 ]. Acute unilateral cervical subsequent healing by fi brosis [ 1 ]. The tumor can be lymphadenitis is caused by S. pyogenes or S. aureus moved from side to side but not upward or downward. in 40% to 80% of cases [ 6 , 12 ]. The classical cervical Torticollis is usually present. lymphadenopathy in Kawasaki disease is usually acute and unilateral. Typically, acute suppurative lymphadeni- Cervical ribs tis is caused by S. aureus or S. pyogenes [ 13]. S ubacute Cervical ribs are orthopedic anomalies that are usually or chronic cervical lymphadenitis is often caused by bilateral, hard, and immovable. Diagnosis is established B. henselae , Toxoplasma gondii , EBV, CMV, nontuber- with a radiograph of the neck. culosis mycobacteria, and M. tuberculosis [ 1 , 11 ]. Less common causes include syphilis, Nocardia brasiliensis, Cystic hygroma and fungal infection. A cystic hygroma is a multiloculated, endothelial-lined cyst that is diffuse, soft, and compressible, contains lym- Associated symptoms phatic fl uid, and typically transilluminates brilliantly. Fever, sore throat, and cough suggest an upper respira- tory tract infection. Fever, night sweats, and weight loss Hemangioma suggest lymphoma or tuberculosis. Recurrent cough and A hemangioma is a congenital vascular anomaly that hemoptysis are indicative of tuberculosis. Unexplained often is present at birth or appears shortly thereafter. The fever, fatigue, and arthralgia raise the possibility of col- mass is usually red or bluish. lagen vascular disease or serum sickness. Concurrent illness and past health Laryngocele A laryngocele is a soft, cystic, compressible mass that Preceding tonsillitis suggests streptococcal infection. Recent extends out of the larynx and through the thyrohy- facial or neck abrasion or infection suggests staphylococ- oid membrane and becomes larger with the Valsalva cal infection. Periodontal disease might indicate infections maneuver. There might be associated stridor or hoarse- caused by anaerobic organisms. A history of cat-scratch ness. A radiograph of the neck might show an air fl uid raises the possibility of B. henselae infection. A history of level in the mass. dog bite or scratch suggests specifi c causative agents such as Pasteurella multocida an d S. aureus. L ymphadenopathy Dermoid cyst resulting from CMV, EBV, or HIV might follow a blood transfusion. The immunization status of the child should A dermoid cyst is a midline cyst that contains solid and cystic components. It seldom transilluminates as bril- be determined. Immunization-related lymphadenopathy liantly as a cystic hygroma. A radiograph might show that might follow diphtheria-pertussis-tetanus, poliomyelitis, or it contains calcifi cations. typhoid fever vaccination. Drug use The response of cervical lymphadenopathy to specifi c Clinical Evaluation antimicrobial therapies might help to confi rm or exclude A detailed history and a thorough physical examination are essential in the evaluation of the child with cervical a diagnosis. Lymphadenopathy might follow the use of lymphadenopathy. medications such as phenytoin and isoniazid. 186 Upper Respiratory, Head, and Neck Infections Table 2. Differentiation of nontuberculosis mycobacterial and Mycobacterium tuberculosis cervical lymphadenitis Clinical characteristics Non tuberculosis mycobacteria M. tuberculosis Age 1 to 4 y Al l ages (most > 5 y) Race Predominantly white Predominantly black or Hispanic Exposure to tuberculosis Ab sent Present Constitutional symptoms Absent Present Cervical lymphadenitis Usually solitary, in submandibular area Usually multiple, bilateral, in posterior cervical or supraclavicular area Sinus tract formation Approximately 10% Rare Chest radiograph Norm al (97%) A bnormal (20%–70%) Residence Ru ral Urban PPD > 15 mm of induration* Un common Usual Response to antimycobacterial drugs No Yes *PPD refers to 5 tuberculin units (5 TU) intradermal skin test. Exposure to infection pathogen is present, the nodes can be either unilateral or Exposure to a person with an upper respiratory tract bilateral, are usually tender, might be fl uctuant, and are infection, streptococcal pharyngitis, or tuberculosis sug- not fi xed. The presence of erythema and warmth sug- gests the corresponding disease. A history of recent travel gests an acute pyogenic process, and fl uctuance suggests should be sought. abscess formation. A “cold” abscess is characteristic of infection caused by mycobacteria, fungi, or B. henselae. Physical examination In patients with tuberculosis, the nodes might be matted General or fl uctuant, and the overlying skin might be erythema- Malnutrition or poor growth suggests chronic disease tous but is typically not warm [ 8 ]. Clinical features that such as tuberculosis, malignancy, or immunodefi ciency. help differentiate nontuberculosis mycobacterial cervical lymphadenitis from M. tuberculosis cervical lymphad- Characteristics of the lymph tissue enitis are summarized in Table 2 [ 3 , 15 ]. Approximately All accessible node-bearing areas should be examined to 50% of patients with lymphadenitis caused by nontu- determine whether the lymphadenopathy is generalized. berculosis mycobacteria develop fl uctuance of the lymph The nodes should be measured for future comparison [ 1 ]. node and spontaneous drainage; sinus tract formation Fluctuation in size of the nodes suggests a reactive pro- occurs in 10% of affected patients [ 4••, 16••]. I n lymph- cess, whereas relentless increase in size indicates a serious adenopathy resulting from malignancy, signs of acute pathology [ 1 , 14]. T enderness, erythema, warmth, mobil- infl ammation are absent, and the lymph nodes are hard ity, fl uctuance, and consistency should be assessed. and often fi xed to the underlying tissue. The location of involved lymph nodes often gives clues to the entry site of the organism and should prompt Associated signs a detailed examination of that site. Submandibular and A thorough examination of the ears, eyes, nose, oral submental lymphadenopathy is most often caused by cavity, and throat is necessary. Acute viral cervical lymph- an oral or dental infection, although this feature may adenitis is variably associated with fever, rhinorrhea, also be seen in cat-scratch disease and non-Hodgkin’s conjunctivitis, pharyngitis, and sinus congestion [ 4••]. A lymphoma. Acute posterior cervical lymphadenitis is beefy red throat, exudate on the tonsils, petechiae on the classically seen in persons with rubella and infectious hard palate, and a strawberry tongue suggest infection mononucleosis [1 , 11] . Supraclavicular or posterior caused by S. pyogenes [ 1 ]. Unilateral facial or submandib- cervical lymphadenopathy carries a much higher risk ular swelling, erythema, tenderness, fever, and irritability for malignancy than does anterior cervical lymphade- in an infant suggest group B streptococcal infection [ 13]. nopathy. Cervical lymphadenopathy associated with Diphtheria is associated with edema of the soft tissues of generalized lymphadenopathy is often caused by a viral the neck, often described as “bull-neck” appearance. The infection. Malignancies (eg, leukemia or lymphoma), col- presence of gingivostomatitis suggests infection with HSV, lagen vascular diseases (eg, juvenile rheumatoid arthritis whereas herpangina suggests infection with coxsackievi- or systemic lupus erythematosus), and some medications rus [ 11 ]. Rash and hepatosplenomegaly suggest EBV or are also associated with generalized lymphadenopathy. CMV infection [4• •] . The presence of pharyngitis, macu- In lymphadenopathy resulting from a viral infec- lopapular rash, and splenomegaly suggest EBV infection tion, the nodes are usually bilateral and soft and are [ 17]. C onjunctivitis and Koplik spots are characteristics of not fi xed to the underlying structure. When a bacterial rubeola. The presence of pallor, petechiae, bruises, sternal Cervical Lymphadenitis: Etiology, Diagnosis, and Management Leung and Davies 187 I I tenderness, and hepatosplenomegaly suggests leukemia. part of the lymph node for biopsy [ 22 ]. The technique Prolonged fever, conjunctival infection, oropharyngeal also allows detection of small lymphadenopathies. mucous membrane infl ammation, peripheral edema or Fine-needle aspiration and culture of a lymph node erythema, and a polymorphous rash are consistent with is a safe and reliable procedure to isolate the causative Kawasaki disease. organism and to determine the appropriate antibiotic when bacterial infection is the cause [ 23 ]. Failure to improve or worsening of the patient’s condition while on Diagnostic Evaluation antibiotic treatment is an indication for fi ne-needle aspi- Laboratory tests are not necessary in most children with cer- ration and culture [4• •]. A ll aspirated material should be vical lymphadenopathy. A complete blood cell count might sent for Gram and acid-fast stain and cultures for aerobic help to suggest a bacterial lymphadenitis, which is often and anaerobic bacteria, mycobacteria, and fungi [ 4••, 24 ]. accompanied by leukocytosis with a shift to the left and If the Gram stain is positive, only bacterial cultures are toxic granulations. Atypical lymphocytosis is prominent in mandatory. Polymerase chain reaction testing is a fast and infectious mononucleosis [ 17] . Pancytopenia, leukocytosis, useful technique for the demonstration of mycobacterial or the presence of blast cells suggests leukemia. The eryth- DNA fragments [ 15 ]. rocyte sedimentation rate and C-reactive protein are usually An excisional biopsy with microscopic examination signifi cantly elevated in persons with bacterial lymphadeni- of the lymph node might be necessary to establish the tis. Blood culture should be obtained if the child appears diagnosis if symptoms or signs of malignancy are present toxic. A rapid streptococcal antigen test or a throat culture or if the lymphadenopathy persists or enlarges in spite of might be useful to confi rm a streptococcal infection [18 ]. appropriate antibiotic therapy and the diagnosis remains An electrocardiogram and echocardiogram are indicated if in doubt [ 5 ]. The biopsy should be performed on the larg- Kawasaki disease is suspected. est and fi rmest node that is palpable, and the node should Skin tests for tuberculosis should be performed in patients be removed intact with the capsule [1 , 10 ]. with subacute or chronic adenitis. Chest radiography should be performed if the tuberculin skin test is positive or if an underlying chest pathology is suspected, especially in the Management child with chronic or generalized lymphadenopathy. Sero- Treatment of cervical lymphadenopathy depends on the logic tests for B. henselae, EBV, CMV, brucellosis, syphilis, underlying cause. Most cases are self-limited and require and toxoplasmosis should be performed when indicated. If no treatment other than observation. This applies espe- the serology is positive, the diagnosis can be established and cially to small, soft, and mobile lymph nodes associated excision biopsy can be avoided [19 • ]. with upper respiratory infections, which are often viral in Ultrasonography (US) is the most useful diagnostic origin. These children require follow-up in 2 to 4 weeks. imaging modality in the assessment of cervical lymph The treatment of acute bacterial cervical lymphadenitis nodes. US may help to differentiate a solid mass from a without a known primary infectious source should provide cystic mass and to establish the presence and extent of adequate coverage for both S. aureus and S. pyogenes , suppuration or infi ltration. High-resolution and color US pending the results of the culture and sensitivity tests [ 5 ]. can provide detailed information on the longitudinal and Appropriate oral antibiotics include cloxacillin, cephalexin, transverse diameter, morphology, texture, and vascular- cefprozil, or clindamycin [ 6 ]. Children with cervical lymph- ity of the lymph node [ 4••, 14]. A l ong-to-short axis ratio adenopathy and periodontal or dental disease should be greater than 2 suggests benignity, whereas a ratio less treated with clindamycin or a combination of amoxicillin than 2 suggests malignancy [ 14 ]. In lymphadenitis caused and clavulanic acid, which provide coverage for anaerobic by an infl ammatory process, the intranodal vasculature is oral fl ora [ 6 , 25 ]. Referral to a pediatric dentist for treat- dilated, whereas in lymphadenopathy secondary to neo- ment of the underlying periodontal or dental disease is plastic infi ltration, the intranodal vasculature is usually warranted. Antimicrobial therapy may have to be modifi ed distorted. Absence of an echogenic hilus and overall lymph once a causative agent is identifi ed, depending on the clini- node hyperechogenicity are suggestive of malignancy cal response of the existing treatment. Because of its proven [ 20• ]. US can also be used to guide core-needle biopsy effi cacy, safety, and narrow spectrum of antimicrobial for diagnosing the cause of cervical lymphadenopathy activity, penicillin remains the drug of choice for adenitis in patients without known malignancy and may obviate caused by S. pyogenes , except in patients allergic to penicil- unnecessary excisional biopsy [21 •] . Advantages of US lin [ 7 ]. Methicillin-resistant S. aureus i s resistant to many include cost-effectiveness, noninvasiveness, and absence kinds of antibiotics. Currently, vancomycin is the drug of radiation hazard. A potential drawback is its lack of of choice for complicated cases, although trimethoprim- absolute specifi city and sensitivity in ruling out neoplastic sulfamethoxazole or clindamycin is often adequate for processes as the cause of lymphadenopathy [4• •]. uncomplicated outpatient management [26 ]. Diffusion-weighted MRI with apparent diffusion coef- In most patients, symptomatic improvement should fi cient mapping can be helpful to differentiate malignant be noted after 48 to 72 hours of therapy. Fine-needle from benign lymph nodes and delineate the solid, viable aspiration and culture should be considered if there is no 188 Upper Respiratory, Head, and Neck Infections clinical improvement or if the patient’s condition dete- Acknowledgment riorates. If the lymph nodes become fl uctuant, incision This article was published in part by Leung and Robson and drainage should be performed. Failure of regres- [ 1 ] in the Journal of Pediatric Health Care, w ith permis- sion of lymphadenopathy after 4 to 6 weeks might be an sion from Elsevier. It has been signifi cantly updated for indication for a diagnostic biopsy [ 12 ]. Indications for the current article. early excision biopsy for histology include lymph node in the supraclavicular area, lymph node larger than 3 cm, lymph nodes in children with a history of malignancy, Disclosure and clinical fi ndings of fever, night sweats, weight loss, No potential confl icts of interest relevant to this article and hepatosplenomegaly [ 19• ]. were reported. Toxic or immunocompromised children and those who do not tolerate, will not take, or fail to respond to oral medi- cation should be treated with intravenous nafcillin, cefazolin, References and Recommended Reading or clindamycin [6 ]. 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Journal

Current Infectious Disease ReportsPubmed Central

Published: Apr 18, 2009

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