SIGNS AND SYMPTOMS 
- Painful swelling, inflammation/infection of lymph nodes
- Commonly presents simultaneously with acute cellulitis or abscess if pyogenic cause
- Axillary lymphadenitis:
- Fever, axillary pain, and acute lymphedema of arms and chest, without features of cellulitis or lymphangitis; ipsilateral pleural effusion may be present
History
- Occupation
- Exposure to pets
- Sexual behavior
- Drug use
- Travel history
- Associated symptoms:
- Duration of lymphadenopathy
Physical Exam
- Extent of lymphadenopathy (localized or generalized)
- Size of nodes:
- Abnormal size by site:
- General: > 1 cm
- Epitrochlear: > 0.5 cm
- Inguinal: > 1.5 cm
- Presence or absence of nodal tenderness
- Signs of inflammation over node
- Skin lesions
- Splenomegaly
- Enlargement of supraclavicular or scalene nodes is always abnormal
ESSENTIAL WORKUP
- Acute regional lymphadenitis is clinical diagnosis, often part of larger syndrome (cellulitis)
- History and physical exam to reveal infectious source
DIAGNOSIS TESTS & INTERPRETATION
Lab
- WBC is not essential:
- CBC, Epstein–Barr virus (EBV), cytomegalovirus (CMV), HIV, and other serologies based on clinical findings
Imaging
US or CT in patients who do not improve or progress to suppuration
Diagnostic Procedures/Surgery
Consider percutaneous needle aspiration or surgical drainage in patients who do not improve or progress to suppuration
DIFFERENTIAL DIAGNOSIS
Pediatric Considerations
[Outline]
INITIAL STABILIZATION/THERAPY
Ensure airway, breathing, and circulation management and hemodynamic stability
ED TREATMENT/PROCEDURES
- General principles:
- Antibiotics based on involved primary organ/suspected pathogen (see also "Cellulitis")
- Consider local prevalence of MRSA and other resistant pathogens in addition to usual causes
- Usual outpatient treatment: 7–10 days
- Elevation
- Application of moist heat
- Analgesics
- Drainage of abscesses if present:
- Obtain culture if drainage performed, especially to help identify resistant pathogens
- Skin origin:
- Pharyngeal or periodontal origin:
- Axillary lymphadenitis:
- Outpatient:
- Oral penicillin VK
- Alternatives: Oral macrolide or amoxicillin/clavulanate
- Inpatient:
- IV penicillin G (aqueous)
- Alternatives: IV ampicillin/sulbactam
- Acute unilateral cervical suppurative lymphadenitis:
- Outpatient:
- Oral penicillin VK
- Alternatives: Oral clindamycin or amoxicillin/clavulanate
- MRSA:
- Nosocomial MRSA:
- CA-MRSA:
- PO: TMP/SMX, clindamycin or doxycycline
- IV: Vancomycin or clindamycin
MEDICATION
- Amoxicillin/clavulanate: 500–875 mg (peds: 45 mg/kg/24 h) PO BID or 250–500 mg (peds: 40 mg/kg/24 h) PO TID
- Ampicillin/sulbactam: 1.5–3 g (peds: 100–300 mg/kg/24 h up to 40 kg; > 40 kg, give adult dose) IV q6h
- Cephalexin: 500 mg (peds: 50–100 mg/kg/24 h) PO QID
- Clindamycin: 450–900 mg (peds: 20–40 mg/kg/24 h) PO or IV q6h
- Dicloxacillin: 125–500 mg (peds: 12.5–25 mg/kg/24 h) PO q6h
- Doxycycline: 100 mg PO BID for adults
- Erythromycin base: (adult) 250–500 mg PO QID
- Linezolid: 600 mg PO or IV q12h (peds: 30 mg/kg/d divided q8h)
- Metronidazole: (adult) 15 mg/kg IV once, followed by 7.5 mg/kg IV q6h
- Nafcillin: 1–2 g IV q4h (peds: 50–100 mg/kg/24 h divided q6h); max. 12 g/24 h
- Penicillin VK: 250–500 mg (peds: 25–50 mg/kg/24 h) PO q6h
- Penicillin G (aqueous): 4 mIU (peds: 100,000–400,000 U/kg/24 h) IV q4h
- Rifampin: 600 mg PO BID for adults
- TMP/SMX: 2 DS tabs PO q12h (peds: 6–10 mg/kg/24 h TMP divided q12h)
- Vancomycin: 1 g IV q12h (peds: 10 mg/kg IV q6h, dosing adjustments required age < 5 yr); check serum levels
[Outline]
DISPOSITION
Admission Criteria
- Toxic appearing
- History of immune suppression
- Concurrent chronic medical illnesses
- Unable to take oral medications
- Unreliable patients
Discharge Criteria
- Mild infection in a nontoxic-appearing patient
- Able to take oral antibiotics
- No history of immune suppression or concurrent medical problems
- Has adequate follow-up within 24–48 hr
Issues for Referral
- If not found in context of acute infection and not quick to resolve with course of antibiotics, evaluate for more serious underlying causes (e.g., malignancy)
- Lymph node biopsy may be helpful in the following circumstances:
- Clinical findings indicate likely malignancy
- Lymph node size > 1 cm
- Supraclavicular location
FOLLOW-UP RECOMMENDATIONS
- Follow-up within 24–48 hr for response to treatment
- If symptoms worsen—including new or worsening lymphangitis, new or increasing area of redness over the node, worsening fever—patient should be instructed to return sooner
[Outline]
- Abrahamian FM, Talan DA, Moran GJ. Management of skin and soft-tissue infections in the emergency department. Infect Dis Clin North Am. 2008;22:89–116.
- Boyce JM. Severe streptococcal axillary lymphadenitis. N Engl J Med. 1990;323:655–658.
- Henry PH, Longo DL. Enlargement of lymph nodes and spleen. In: Longo DL, Kasper DL, Jameson JL, et al., eds. Harrison's Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill;2012:465–471.
- Pasternack MS, Swartz MN. Lymphadenitis and lymphangitis. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 7th ed. New York, NY: Elsevier/Churchill Livingstone; 2010:1323–1333.
- Thomas KT, Feder HM Jr, Lawton AR, et al. Periodic fever syndrome in children. J Pediatr. 1999;135:15–21.
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