Author:
JohnMahoney
DoloresGonthier
Description
- Lymph nodes are inflamed causing enlargement and tenderness
- Become engorged with lymphocytes and macrophages
- May be infected
- Classified by location and acuity of node enlargement
- Acute regional
- Infection in distal extremity may result in adenitis proximally
- Acute suppurative lymphadenitis may occur after pharyngeal or skin infection
- Causes of chronic regional and systemic lymphadenitis are mentioned in this chapter, but are more fully discussed in disease-specific chapters
Etiology
- Cervical:
- Viral: common, usually bilateral adenitis
- Bacterial: Common, either bilateral or unilateral, more likely to be suppurative
- Skin origin: Staphylococcus aureus: Both methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA), group A β-hemolytic Streptococcus
- Staph risk factors discussed below
- Pharyngeal origin: Group A β-hemolytic Streptococcus
- Periodontal origin: Group A β-hemolytic Streptococcus and anaerobes
- Mycobacterium tuberculosis, atypical mycobacterium - uncommon; subclinical course
- Bartonella henselae: Cat-scratch disease; subclinical course
- Axillary:
- Streptococcus pyogenes (group A β-hemolytic Streptococcus)
- Fever, axillary pain, and acute lymphedema of arms and chest, without features of cellulitis or lymphangitis; ipsilateral pleural effusion may be present; primary source arm or hand
- Skin origin: S. aureus and group A β-hemolytic Streptococcus
- B. henselae: Cat-scratch disease
- Most common lymph node region affected, subclinical course
- Inguinal:
- Skin origin: Usually unilateral
- S. aureus: Both MSSA and MRSA, group A β-hemolytic Streptococcus
- Sexually transmitted disease: Can be unilateral or bilateral
- Syphilis (primary and secondary)
- Lymphogranuloma venereum (LGV) - Chlamydia trachomatis
- Chancroid
- Primary genital herpes
- B. henselae: Cat-scratch disease
- Usually unilateral, subclinical course
- Yersinia pestis: Bubonic plague:
- Exposure to fleas from rodents or rabbits in western U.S.
- Seen in hunters, backpackers, rural workers
- S. aureus risk factors
- Staph (MSSA and MRSA) more common in suppurative adenitis and /or abscess formation
- Risk factors for Staph infection (MSSA and MRSA):
- Recent hospital or long-term care admission
- Recent surgery
- Children
- Soldiers
- Incarcerated persons
- Athletes in contact sports
- Injection drug use
- Men who have sex with men
- Dialysis treatments and catheters
- History of penetrating trauma
- Additional risk factors for MRSA infection:
- Prior MRSA infection
- MRSA colonization
- Area of high MRSA incidence, close contact with MRSA patient
- Systemic lymphadenitis/lymphadenopathy:
- HIV
- EBV, CMV
- Toxoplasmosis, acute
- Miliary tuberculosis
- Secondary syphilis
- Leptospirosis
Pediatric Considerations |
- Acute unilateral cervical suppurative lymphadenitis:
- Most common at age <6 yr
- Group A Streptococcus, S. aureus, and anaerobes are most common causes
- Source is pharyngeal or scalp
- Acute torticollis possible
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Signs and Symptoms
- Painful swelling, inflammation/infection of lymph nodes
- Commonly presents simultaneously with acute cellulitis or abscess if bacterial etiology
History
- Occupation
- Exposure to animals (cats, rodents, rabbits)
- Sexual behavior
- Drug use
- Travel history
- Trauma history
- Associated symptoms:
- Sore throat
- Cough
- Fever
- Night sweats
- Fatigue
- Weight loss
- Pain in nodes
- Duration of lymphadenopathy
Physical Exam
- Fever, other signs of systemic illness
- 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 nodes
- Fluctuance or other evidence of suppuration or abscess
- Skin/genital lesions
- Signs of pharyngeal or dental infections
- Splenomegaly
- Enlargement of supraclavicular or scalene nodes is always abnormal
Essential Workup
- Acute regional lymphadenitis is clinical diagnosis, often part of larger syndrome (e.g., cellulitis)
- History and physical exam to reveal infectious source
Diagnostic Tests & Interpretation
Lab
- WBC is not essential:
- Possible leukocytosis with left shift or normal
- CBC, TB testing, Epstein-Barr virus (EBV), cytomegalovirus (CMV), HIV, and other serologies based on clinical findings
- Blood cultures may reveal causative organism
Imaging
- US and CT to identify abscess if:
- Exam equivocal
- Lack of improvement on appropriate therapy
- Progression to suppuration
- CT can be used to assess involvement of deep lymph nodes
Diagnostic Procedures/Surgery
- Consider percutaneous needle aspiration or surgical drainage if:
- Lack of improvement on appropriate therapy
- Progression to suppuration
- Present with abscess
- Significant systemic signs or sepsis
- Suspicion of unusual or resistant organism
Differential Diagnosis
- Infectious:
- Anthrax
- Dengue
- Diphtheria
- Filariasis, bancroftian
- Fungal
- Herpes Zoster
- Infectious hepatitis
- Rubella
- Scarlet fever
- Sporotrichosis (rose thorns)
- Typhoid
- Varicella (chicken pox)
- West Nile fever
- Noninfectious:
- Adjacent metal prosthesis
- Amyloidosis
- Malignancy, especially lymphoma
- Phenytoin reaction
- Rheumatologic disorders
- Sarcoidosis
- Serum sickness
- Silicone implants
- Systemic lupus erythematosus
Pediatric Considerations |
- Kawasaki disease
- PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis)
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Initial Stabilization/Therapy
Ensure airway, breathing, and circulation management and hemodynamic stability
ED Treatment/Procedures
- General treatments:
- Elevation
- Application of moist heat
- Analgesics
- General principles:
- Antibiotics based on involved primary organ/suspected pathogen (see also “Cellulitis”)
- Consider local prevalence of MRSA and other unusual or resistant pathogens in addition to usual causes
- Outpatient treatment duration is at least 10 d
- Treatment may need to include MRSA coverage based on:
- Presence of MRSA risk factors, especially the MRSA prevalence in the local area
- Severity of systemic symptoms
- Presence of an abscess
- Suspected pathogen
- Drainage of abscesses if present:
- Obtain culture if drainage performed, especially to help identify resistant or uncommon pathogens
- Cervical
- Skin origin:
- Pharyngeal or periodontal origin:
- Outpatient: Penicillin VK; Alternatives: Clindamycin or amoxicillin/clavulanate
- Inpatient: IV penicillin G (aqueous); Alternatives: IV ampicillin/sulbactam or IV clindamycin
- Axillary:
- S. pyogenes (group A β-hemolytic Streptococcus):
- Outpatient: Penicillin VK; Alternatives: Amoxicillin/clavulanate or clindamycin
- Inpatient: IV penicillin G (aqueous); Alternatives: IV ampicillin/sulbactam or IV clindamycin
- Skin origin:
- Outpatient: Cephalexin; Alternatives: Dicloxacillin, clindamycin
- Inpatient: IV nafcillin or IV cefazolin
- Inguinal:
- Skin origin:
- Outpatient: Cephalexin; Alternatives: Dicloxacillin, clindamycin
- Inpatient: IV nafcillin or IV cefazolin
- Acute unilateral cervical suppurative lymphadenitis:
- Outpatient:
- Penicillin VK
- Alternatives: Clindamycin or amoxicillin/clavulanate
- MRSA treatment: Add the following if suspicion that MRSA could be etiologic agent
- Outpatient:
- TMP/SMX
- Alternative: Doxycycline
- Inpatient:
- IV Vancomycin
- Alternative: IV linezolid
Medication
- Amoxicillin/clavulanate: 875 mg PO b.i.d or 500 mg PO t.i.d (peds: 7:1 formulation: 45 mg/kg/24 hr) PO q12h
- Ampicillin/sulbactam: 1.5-3 g (peds: 100-300 mg/kg/24 hr up to 40 kg; over 40 kg, give adult dose) IV q6h
- Cefazolin: 1-1.5 g (peds: 50-100 mg/kg/24 hr; max. 6 g/24 hr) IV q8h
- Cephalexin: 500 mg (peds: 25-50 mg/kg/24 hr; max. 4 g/24 hr) PO q.i.d
- Clindamycin: 300-450 mg (peds: 30-40 mg/kg/24 hr) PO q6h; 600 mg (peds: 25-40 mg/kg/24 hr) IV q8h
- Dicloxacillin: 250-500 mg (peds: 12.5-25 mg/kg/24 hr) PO q6h
- Doxycycline: 100 mg PO b.i.d for adults
- Linezolid: 600 mg (peds <12 yo: 30 mg/kg/24 hr) PO or IV q12h
- Nafcillin: 1-2 g IV q4h (peds: 100-200 mg/kg/24 hr IV q6h); max. 12 g/24 hr
- Penicillin VK: 250-500 mg (peds: 25-75 mg/kg/24 hr) PO q6h
- Penicillin G (aqueous): 2-4 million units (peds: 150,000-300,000 units/kg/24 hr, max. 12-20 million units) IV q4-6h
- Trimethoprim/sulfamethoxazole (TMP/SMX):1-2 DS tabs (peds: 8-12 mg/kg/24 hr based on TMP component) PO q12h
- Vancomycin: 30-40 mg/kg/24 hr IV q8-12h, do not exceed 4 g/24 hr or 2 g/dose (peds: 40 mg/kg/24 hr q6h; dosing adjustments required younger than age 5 yr); check serum levels
Disposition
Admission Criteria
- Toxic appearing
- Signs of systemic illness
- Marked lymph node enlargement
- History of immune suppression
- Concurrent chronic medical illnesses
- Unable to take oral medications
- Unreliable patients
- Failed outpatient treatment
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 or excision may be helpful in the following circumstances:
- No clear relationship to infectious origin
- 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
- HealyCM, BakerCJ. Cervical lymphadenitis. In: CherryJD, HarrisonGJ, KaplanSL, et al., eds. Feigin and Cherry's Textbook of Pediatric Infectious Diseases. 8th ed.Philadelphia, PA: Elsevier; 2018:124-133.
- LeungAK, DaviesHD. Cervical lymphadenitis: Etiology, diagnosis, and management . Curr Infect Dis Rep. 2009;11:183-189.
- PasternackMS, SwartzMN. Lymphadenitis and lymphangitis. In: BennettJE, DolinR, BlaserMJ, eds. Mand ell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed.New York: Elsevier/Churchill Livingstone; 2014:1226-1237.
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