Newsletters

POSTED: October 14th, 2022
POSTED IN: EM Pulse - The Official Newsletter of MOCEP, September/October 2022,

Emily Wynia, MD
Pediatric Emergency Medicine Fellow, Emergency Medicine Physician, St. Louis Children’s Hospital

Cervical lymphadenitis is a common diagnosis found in the pediatric population. Lymphadenitis is defined as lymphadenopathy caused by an inflammatory process [1], yet clinically, the term is more often used to indicate bacterial etiology. Cervical lymphadenitis often presents in young, nonverbal children with nonspecific symptoms, which makes it tricky to diagnose and, at times, not appreciated by even the most astute clinicians.  On follow-up review, these cases often have subtle clues in the history and physical exam that could have led the provider to the correct diagnosis.  Left untreated, children with cervical lymphadenitis are at risk of systemic spread of the infection and abscess formation requiring surgical drainage. This article aims to educate emergency medicine providers on how to suspect, detect and treat cervical lymphadenitis. 

Clinical Presentation  

As always, a thorough history and physical exam is the most cost-effective diagnostic tool available to the emergency medicine provider.  In children with cervical lymphadenitis, caregivers often bring the patient in for nonspecific symptoms such as fever and irritability.  However, on further history, the patient may have more unique symptoms specific to lymphadenitis. The parent might note that the child prefers to sleep with their head turned to one side and cries when it is moved in the other direction.  Furthermore, it is important to determine the patient’s immunization status and inquire about ingestion of unpasteurized foods (brucellosis, Mycobacterium bovis), travel history (TB) and animal exposures (toxoplasmosis [cats], tularemia [rabbits]) as this history can help dictate the treatment plan. 

Cervical lymphadenopathy can be a common finding, with the prevalence in otherwise healthy children estimated at 38-45% [2]. However, there are several key physical exam findings that can help differentiate its severity.  The provider should observe the child’s neck mobility and check the neck for swelling, warmth or pain with movement.  The size, location, quantity, and consistency of the lymph nodes should be noted, as these can be important clues [3].  Soft, small, mobile, and mildly tender nodes are usually reactive and are often due to viral infection.  Asymmetric, tender, and warm lymph nodes are likely bacterial and termed lymphadenitis.  Fluctuant nodes with overlying erythema or drainage of fluid would raise suspicion for suppurative infection or abscess.   Firm, nonmobile and bilateral lymph nodes cause concern for malignancy, such as lymphoma. 

Diagnostic Work up

Although obtaining viral swabs for seasonal pathogens can help hone in on a diagnosis, oftentimes they do not change management and are not recommended.  Specific testing for infectious mononucleosis due to EBV or CMV can aid in long-term precautions for splenomegaly and follow up.  Streptococcus pyogenes (GAS) throat swab should be obtained if the child is an appropriate age and has associated exudative tonsillitis.  The CDC does not recommend GAS testing in children less than 3 years of age [4]. Ultrasound of the lymph node is obtained when the provider is concerned for possible abscess or vascular malformation.  Further imaging with a contrast-enhanced CT is indicated when the patient presents with more worrisome symptoms of trismus, voice changes, trouble swallowing or sore throat [5].  In these cases, the diagnosis is more likely not isolated lymphadenitis, and a CT can provide more detail on the extent of the mass in relation to the airway, detect deeper neck space infections (retropharyngeal abscess) and rule out complications with surrounding vessels (compression or thrombosis).  Referral for biopsy of the lymph node is made when the clinician is concerned for malignancy. 

Management 

In general, reactive lymphadenopathy appears with a viral prodrome and disappears when the symptoms resolve.  Supportive care is the mainstay of treatment in these patients.   Bacterial lymphadenitis usually does not coincide with viral symptoms (rhinorrhea, cough) and the patient will typically present with fever, neck swelling and neck pain [6].  The most common bacterial species associated with cervical lymphadenitis include Staphylococcus aureus, Streptococcus pyogenes (GAS), anaerobic infections and group B streptococcus (in neonates) [7]. The initial antibiotic coverage should be administered orally and is determined by the rate of methicillin- or clindamycin-resistant S. aureus in the region.  If the patient’s history does not point to a specific pathogen, first line agents include clindamycin, amoxicillin/clavulanate, or macrolides that are continued for 10-14 days [8].  The patient can be safely discharged home with follow-up in 72 hours to ensure that the infection is healing.  If the lymphadenitis does not improve within this time period or if the patient has severe symptoms (ill-appearing, sepsis syndrome, large fluctuant mass) the clinician should have high suspicion for resistant infection or abscess formation.  Referral for needle aspiration or surgical drainage would be indicated at this time for source control and to obtain wound cultures with antibiotic susceptibilities.  The patient should be admitted for parental antibiotics until they demonstrate clinical improvement.

In summary, fever, both with and without cervical lymphadenopathy, is common in pediatrics.  Being able to delineate between reactive lymphadenopathy and bacterial cervical lymphadenitis can prevent the dangerous complications of abscess formation or sepsis syndrome that may otherwise occur if missed by the clinician. Thus, it is imperative that the emergency medicine provider suspects, readily detects and treats cervical lymphadenitis after recognizing its signs on history and physical exam.

References

1.     Gosche   JR,   Vick   LV:   Acute, subacute, and chronic cervical lymphadenitis in children.   Semin Pediatr Surg   2006,   15:  99–  106

2.     Larsson L, Bentzon M, Kelly KB, et al. Palpable lymph nodes of the neck in Swedish schoolchildren. Acta Paediatr. 1994; 83:1091-1094.

3.     Healy MC and Edwards MS. Cervical lymphadenitis in children: Diagnostic approach and initial management. UpToDate. March 11, 2022.  

4.     CDC. “Group A Streptococcal Disease”. https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

5.     Talmadge, Jennifer C, et al. Chapter 6 Imaging Evaluation of Common Pediatric Emergencies; Emergency Radiology: The Requisites. Elsevier, Inc, 2017. 

6.     Weinstock MS, Patel NA, Smith LP. Pediatric Cervical Lymphadenopathy. Pediatr Rev. 2018 Sep;39(9):433-443. doi: 10.1542/pir.2017-0249. PMID: 30171054.

7.     Barton LL, Feigin RD. Childhood cervical lymphadenitis: a reappraisal. J Pediatr. 1974;84(6):846–852

8.     Healy CM, Baker CJ. Cervical lymphadenitis. In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 8th ed, Cherry JD, Harrison G, Kaplan SL, et al (Eds), Elsevier, Philadelphia 2018. P.124.