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A. Epidemiology

  1. Enlargement of glands are common in children
  2. Most cases represent a transient response to local or generalized infection
  3. 70-80% of unilateral cervical adenitis occurs in children 1-4 years of age
  4. Adenopathy in anterior cervical chain is almost always infectious
  5. Adenopathy in posterior cervical chain is malignant in 50% of cases

B. Etiology

  1. Infectious: acute adenitis
    1. Viral: Herpesvirus 6, rubella, mumps, EBV, CMV, adenovirus, varicella, HIV
    2. Bacterial (common): S. aureus, S. pyogenes, Haemophilus species, anaerobes
    3. Bacterial (uncommon): F. tularnensis, C. diptheriae, P. multocida,
    4. Neonates (bacterial): S. agalactiae (Group B Strep)
    5. Parasite: Toxoplasma gondii
    6. Fungal: Histoplasma, Coccidiodes, Sporothrix schenkii, Aspergillus, Candida albicans
    7. Other: Rickettsia sp.
    8. S. pyogenes and S. aureus cause 53-89% of unilateral adenitis in children
  2. Infectious: subacute adenitis
    1. Bacterial: Brucella sp., Actinomyces, Nocardia
    2. Other: B. henselae (Cat-Scratch Disease)
    3. Atypical organisms: M. tuberculosis, atypical mycobacterium, T. pallidum (syphilis)
  3. Infectious: generalized adenitis
    1. Bacterial: S. pyogenes (Scarlet Fever), S. typhi (Typhoid fever), Y. pestis, Leptospira
    2. Viral: CMV
    3. Pharyngitis or tonsillitis may cause bilateral cervical adenitis
  4. Non-infectious
    1. Kawaskaki Disease
    2. Childhood periodic fever syndrome
    3. Malignancy: leukemia, lymphoma, neuroblastoma
    4. Infiltrative: sarcoidosis or other granulomatous disease
  5. Childhood Periodic Fever Syndrome [2]
    1. Periodic fever
    2. Aphthous stomatitis
    3. Pharyngitis
    4. Tender cervical adenitis
    5. Usually manifests <5 years
    6. Spontaneous resolution by 4-8 years
    7. Serum IgD level may be elevated, but <100 IU/mL
    8. Response to 1-2mg/kg prednisone given for 1-2 days

C. Anatomy

  1. Anterior cervical chain: in front of sternomastoid
  2. Posterior cervical chain: behind sternomastoid
  3. Submandibular or submaxillary: adjacent to maxillary glands
  4. Submental: below the jaw
  5. Preauricular: in front of ear
  6. Mastoid: posterior auricular
  7. Occipital: overlies the trapezius

D. Pathogenesis

  1. Increase in size of the node results from:
    1. Proliferation of cells intrinsic to the node
    2. Infiltration of cells extrinsic to the node
  2. Lymph nodes filter infectious agents from the lymphatics draining adjacent areas
  3. Initially sinusoidal lining cells swell and leukocytes infiltrate
  4. Suppuration or abscess formation develops in some cases

E. History

  1. Age
  2. Systemic manifestations
  3. Associated infections
    1. Dental: carries, abscess, gum disease
    2. Head: seborrhea, head lice, tinea capitus, abrasions
    3. Skin: impetigo, vesicles
    4. Throat: pharyngitis
    5. Eye: conjunctivitis
  4. Travel
  5. Tuberculosis exposure
  6. Ingestion of undercooked foods or unpasteurized milk

F. Physical Examination

  1. Shoddy adenopathy normal in children (cervical, axillary, inguinal or suboccipital)
  2. Number and location of involved nodes
  3. Presence of erythema, heat, tenderness, lymphangitis, or suppuration
  4. Systemic manifestations: fever, rash, generalized adenopathy or hepatosplenomegally

G. Laboratory Studies

  1. Complete blood count with differential
  2. Erythrocyte sedimentation rate
  3. EBV / Mononucleosis Test: Monospot
  4. Throat culture
  5. PPD (typically >10 mm for MTb and < 10 mm for atypical mycobacteria)
  6. Streptooccal Test: ASLO serologies
  7. Consider B. henselae titers and syphilis serology (RPR)
  8. Consider needle aspirate or biopsy of involved node
  9. Gram, acid fast or Warthin-Starry silver stain
  10. Aerobic and anaerobic culture of infected tissue

H. Radiologic studies

  1. Nodal ultrasound to assess for fluid collection
  2. Alternatively neck CT to delineate anatomy and look for abscess formation
  3. Chest X-Ray for perihilar adenopathy if disseminated process suspected

I. Treatment

  1. Parenteral therapy needed in the following cases
    1. Children under 1 month
    2. Moderate to severe systemic manifestations
    3. Suppurative nodes or overlying cellulitis
  2. Initial antibiotics to cover most likely infectious organisms
  3. Modify regimen according to culture and serologic results
  4. Suspected S. aureus, S. pyogenes, or S. agalactiae
    1. Oral cephalexin or dicloxacillin
    2. Intravenous: nafcillin, cefazolin, or clindamycin
  5. Suspected anaerobes
    1. Oral: penicillin VK, clindamycin
    2. Intravenous: Pencillin G, clindamycin
    3. Suspected B. henselae
  6. Symptomatic therapy
    1. Antimicrobial therapy for severe cases
    2. Rifampin, TMP/SMX, ciproflaxacin or gentamicin very likely improve outcome
  7. Total treatment course for 10-14 days (5 days after symptoms resolve)
  8. Excision biopsy is usually performed if no response after 2-4 weeks of therapy

References

  1. Chesney PJ. 1994. Pediatrics in Rev. 15(7):276 abstract
  2. Drenth JPH and van der Meer JWM. 2001. NEJM. 345(24):1748 abstract