Cervical Adenitis
Cervical Adenitis: Excerpt from Pediatric Infectious Disease
The differential diagnosis of cervical adenitis is extensive and includes acute
and chronic infections, Kawasaki syndrome, and malignancy. The evaluation
process should be logical with the history and physical guiding the subsequent
workup.
Acute Infections associated with Cervical Adenitis
Etiology (Bacterial)
The most common bacterial cause of acute unilateral cervical adenopathy is
infection with
Staphylococcus aureus or Streptococcus pyogenes (group A streptococci). These two organisms are the cause of acute unilateral
disease in more than 80% of cases.
Presentation
There is often sudden onset of fever, swelling, tenderness, and overlying
erythema.
Diagnosis
Diagnosis of acute bacterial adenitis is typically made by the clinical history
and examination.
Management
Therapy is with an antibiotic with activity against both S. aureus and group A streptococci. A first generation cephalosporin or clindamycin can be
used. Children who appear toxic with high fever and decreased oral intake may
need to be managed initially as inpatients; for these children,
ampicillin-sulbactam (Unasyn) is a good intravenous agent. It is often
difficult to predict in a particular patient which nodes will suppurate and
thus require surgical drainage. Serial exams and the use of computed tomography
of the neck are helpful in determining whether the child will require surgery
(Fig. 9.1). Once the child is afebrile and taking fluids well, these serial
examinations can be done as an outpatient while on oral antibiotics.
The traditional surgical approach to suppurative cervical adenitis that had
failed to respond completely to medical management was open incision and
drainage. Drawbacks to this technique included the need for general anesthesia
and a large scar. There is increasing experience with needle aspiration in the
surgical management of suppurative cervical adenitis. The advantage of needle
aspiration over incisional drainage is that general anesthesia may not be
required and surgical scarring may be minimized. Many pediatric surgeons are
now using this technique as a first-line method for suppurative adenitis
unresponsive to antibiotic treatment (Table 9.1).
Etiology (Viral)
Acute bilateral cervical lymphadenitis is frequently caused by viral infections,
including Epstein-Barr virus, cytomegalovirus, and adenovirus.
Presentation
Patients often have associated cough and rhinorrhea.
Diagnosis
Diagnosis of viral adenopathy is usually made clinically, based on associated
symptoms and the absence of fever and erythema, which characterize acute
bacterial disease.
Management
Care in these cases is supportive. It is important to realize that after a viral
infection, the lymph node enlargement may persist for many weeks, even though
the acute symptoms of fever, cough, and coryza have resolved.
Chronic Infections associated with Cervical Adenitis
The two major causes of chronic infectious lymphadenitis in children are
nontuberculous mycobacteria and cat-scratch disease. Additional causes of
chronic infectious lymphadenopathy include toxoplasmosis and actinomycosis.
Nontuberculous Mycobacteria
Etiology
Nontuberculous mycobacteria (NTM) is a common cause of chronic cervical lymphadenitis in children. The nontuberculous mycobacterium that most often causes pediatric adenopathy is Mycobacterium avium-intracellulare (MAI). These organisms are ubiquitous in nature, often found in soil and
contaminated water. The mycobacteria enter the oral cavity and may infect
cervical lymph nodes. Although disseminated MAI is a common illness in
end-stage acquired immunodeficiency disease (AIDS) patients, adenopathy in
pediatrics is not considered a symptom of underlying immunodeficiency.
Presentation
Patients present with chronic lymph node enlargement over several weeks to
months, although occasionally acute infection is seen. Affected nodes progress
to fluctuation with an accompanying overlying violaceous color (Fig. 9.2).
Without treatment, these nodes often rupture and develop sinus tracts.
Diagnosis
NTM infection should be considered in any patient with progressive adenitis not
responding to traditional antibiotics. Needle aspiration often shows white
blood cells but with negative Gram stain and culture. Tuberculin skin testing
for
Mycobacterium tuberculosis (MTB) may reveal a small degree of induration because MTB shares certain
antigens with MAI. There is currently no skin test approved by the U.S. Food
and Drug Administration (FDA) specifically for NTM. Children with MAI adenitis
have negative chest x-rays and are
not contagious.
Management
NTM are not susceptible to traditional antituberculous medications. For this
reason, the treatment of MAI adenitis is complete surgical excision of the
affected node. Excisional biopsy is both diagnostic and therapeutic. The use of
fine-needle aspiration or incision and drainage should be avoided because they
can help facilitate formation of chronic fistula. The gold standard for the
diagnosis of NTM adenitis is culture of the organism. Because growth of
acid-fast bacteria may take several weeks, there has been some investigation
regarding whether the histopathology of the excised node can help differentiate
infections caused by NTM from MTB. Features associated with NTM infection
include lack of significant caseation and less defined granuloma formation.
There are instances in which the clinician will need to start antituberculous
therapy pending final culture results.
In the cases in which complete excision is not possible because of extensive
disease, medical therapy can be attempted. For
Mycobacterium avium complex, a macrolide antibiotic such as clarithromycin or azithromycin, combined
with ethambutol, is recommended.
Mycobacterium tuberculosis
Etiology
MTB is an unusual cause of cervical adenitis in developed countries.
Transmission is person to person, with initial infection caused by aerosolized
bacteria. After deposition in pulmonary alveoli, mycobacteria can travel
through the lymphatic vessels to cervical lymph nodes.
Presentation of MTB adenitis can be similar to adenitis from NTM, with chronic
infection progressing to purplish discoloration and fistula formation.
Diagnosis
Major distinguishing points of NTB adenitis include purified protein derivative
(PPD), which often has greater than 15 mm of induration. Chest radiographs may
reveal hilar adenopathy. Excisional biopsy and culture are often needed for
definitive diagnosis.
Management
Unlike NTM adenitis, treatment is medical with at least two antituberculous
medications effective against the mycobacteria (see chapter 12).
Cat-Scratch Disease
Etiology
Another common cause of chronic adenopathy in children is cat-scratch disease.
This infection is caused by
Bartonella henselae. The organisms are introduced through the skin by a cat scratch or bite; the
most commonly affected area is the upper extremity, resulting in epitrochlear
or axillary node enlargement.
Presentation
Lymphadenopathy is the most common presentation of cat-scratch disease. A
scratch to the facial area may cause significant cervical lymphadenopathy.
B. henselae can also cause additional clinical syndromes, including aseptic meningitis and
encephalitis. Parinaud oculoglandular syndrome is infection with
B. henselae following inoculation of the conjunctiva and presents with conjunctivitis and
periauricular adenopathy.
Diagnosis
A history of cat exposure should always be elicited in evaluation of chronic
cervical adenitis. Diagnosis can be confirmed by serology using indirect
immunofluorescence antibody (IFA). Immunoglobulin G (IgG) antibody titers
higher than 1:512 have been reported to suggest acute infection. IgM antibodies
against
B. henselae have been found only infrequently in the early stages of cat-scratch disease.
Polymerase chain reaction analysis of a lymph node aspirate or biopsy can be
performed, although
B. henselae DNA may be present in lymph nodes only in the first weeks of illness.
Management
Most patients with cat-scratch disease have spontaneous resolution. There is no
consensus on the use of antibiotics for cat-scratch disease. There have been
reports that oral antibiotics, including macrolides,
trimethoprim-sulfamethoxazole, and ciprofloxacin, may be effective. A single
randomized and double-blind placebo-controlled study found that a 5-day course
of oral azithromycin resulted in significant reduction in lymphadenopathy
caused by cat-scratch disease when patients were treated within the first month
of illness. Needle aspiration can be used for nodes that are suppurative and
painful. Unlike chronic adenitis from NTM, surgical excision is generally
neither needed nor advised.
Toxoplasma gondii
Etiology
T. gondii is an intracellular protozoan that is acquired by contact with cats or
consumption of undercooked meats. Toxoplasmosis eventually infects a
significant portion of the adult population.
Presentation
Patients who become symptomatic with this infection often have fever, sore
throat, and posterior cervical adenopathy. Nodes may be mildly tender but as a
rule do not progress to fluctuance. Toxoplasmosis adenopathy can persist for
several months. The clinical course is usually benign and self-limited in the
immunocompetent host.
Diagnosis
Toxoplasmosis adenitis can be diagnosed serologically. Biopsy of affected nodes
reveals characteristic features, including epithelioid cells that encroach on
the margins of lymphoid germinal centers.
Management
No treatment is usually required in patients with normal immune function.
Actinomycosis
Etiology
Actinomyces species are gram-positive bacilli that are acid-fast negative. They are part of
the gastrointestinal tract flora and can cause infection following oral or
facial trauma.
Presentation
Actinomyces species causes three major categories of disease, including cervicofacial,
thoracic, and abdominal. Cervicofacial disease is the most common manifestation
and often occurs after facial trauma or dental procedures. The typical
presentation is progressive swelling and development of a
“woody,” lumpy jaw not responsive to traditional antibiotics. There is increasing
appreciation that cervical facial actinomycosis may often be a polymicrobial
process.
S. aureus or group A streptococci may be involved as a co-pathogen in the development of
cervicofacial disease; when this occurs, an acute painful abscess or cellulitis
may be the initial manifestation. Actinomycosis should be considered in the
proper setting, particularly with progressive cervical adenopathy present in a
patient following significant dental work or facial trauma.
Diagnosis
Biopsy of the affected area reveals beaded and branched acid-fast negative
gram-positive bacilli. Sulfur granules are present in about 25% of cases and
can be visualized in biopsy specimens. Culture of actinomycosis is difficult,
and often the Gram stain and biopsy findings suggest the correct diagnosis.
Management
Therapy of actinomycosis involves high-dose intravenous penicillin G, 100,000 to
250,000 units/kg per day in four divided doses for several months, followed by
oral penicillin, clindamycin, or tetracycline. Duration of therapy is 6 to 12
months. Surgical drainage may be needed for cases that do not respond to
appropriate antimicrobials.
Noninfectious Causes of Cervical Adenopathy
Kawasaki syndrome
Etiology
Kawasaki syndrome is an acute inflammatory illness of unknown etiology. The
original term for Kawasaki syndrome was the
mucocutaneous lymph node syndrome, and cervical adenitis can be a feature of this illness. Most children
diagnosed with Kawasaki syndrome are younger than 5 years of age.
Presentation
The cause of Kawasaki syndrome is unknown; therefore, the diagnosis is based on
clinical criteria. The diagnostic criteria include fever, edema and erythema of
the palms and soles, nonpurulent conjunctivitis, redness of the lips,
strawberry tongue, cervical adenitis, and a skin rash. It is not uncommon for
patients with Kawasaki syndrome to present initially with a unilateral cervical
adenitis, only to progress to the full manifestation of the syndrome. It is for
this reason that children with unilateral cervical adenitis who have continued
fever despite appropriate antibiotics should be evaluated with the Kawasaki
syndrome criteria in mind.
Diagnosis
Diagnosis of Kawasaki syndrome is made by having five of the six clinical
criteria and by exclusion of other syndromes such as viral illnesses or
toxin-producing bacterial disease. Additional non-criteria signs of Kawasaki
disease, including sterile pyuria, marked elevation of the sedimentation rate,
and early growing desquamation, are frequently helpful in the diagnosis.
Thrombocytosis and palmar desquamation after the first 2 weeks of illness are
also characteristic.
A recent study suggested that the cervical lymph nodes in Kawasaki disease may
have specific ultrasonographic features; ultrasound appearance of the inflamed
nodes in Kawasaki syndrome is often a mass of multiple hypoechoic nodes
resembling a cluster of grapes. This is distinct from the ultrasound features
of routine bacterial lymphadenitis and can be helpful in patient evaluation.
The management of Kawasaki syndrome includes the use of intravenous immune
globulin (IVIG) at a dose of 2 mg/kg. High-dose aspirin, 80 to 100 mg/kg per
day in four divided doses, is used until the patient has resolution of fever.
The patient is then maintained on low-dose aspirin, 3 to 5 mg/kg per day for
about 6 weeks until platelet count and sedimentation rate become normal.
Malignant Causes of Cervical Adenopathy
Etiology
The possibility of malignancy in a child with enlarged nodes is always present
in the minds of caretakers. There has been considerable effort made to define
those children whose enlarged lymph nodes may be caused by a malignancy such as
Hodgkin
’s disease, non-Hodgkin’s lymphoma, or leukemia.
Presentation
Up to 30% of children whose adenopathy is caused by a malignancy have associated
fever, anorexia, and weight loss. Additional factors associated with malignancy
include an abnormal chest x-ray and increasing node size. Eosinophilia can also
be seen in patients with Hodgkin
’s disease. Extreme elevation of sedimentation rate, uric acid, and lactate
dehydrogenase (LDH) can be seen. A frequently quoted study from the early 1980s
found that children with supraclavicular adenopathy, unexplained weight loss,
or fixation of the lymph node to overlying skin have a high likelihood of
malignant disease and should be considered for early biopsy.
Diagnosis
The diagnosis of malignancy always requires biopsy.
Management
Therapy is dependent on the particular malignancy diagnosed (Table 9.2).
Evaluation of Pediatric Lymphadenopathy
Testing starts with a complete history and physical examination. Duration of the
lymphadenopathy, along with associated symptoms, including fever, anorexia,
weight
loss, and animal exposure, should always be obtained. Examination of the child
should
be focused on the enlarged lymph node, whether it is red, tender, or fluctuant
and associated organomegaly and lymphadenopathy at other areas.
If a node is consistent with an acute bacterial infection, oral antibiotics can
be given. If the clinical picture suggests a more chronic condition, laboratory
evaluation can include a complete blood count with differential and a metabolic
panel including LDH and uric acid. Chest x-ray looking for hilar adenopathy,
along with a tuberculous skin testing, is also helpful. Serology for particular
pathogens, including toxoplasmosis and cat-scratch disease, may be obtained as
suggested by the history.
Ultimately, nodes that remain enlarged and whose etiology is not defined need to
be considered for excisional biopsy. Fine-needle aspiration is frequently used
to evaluate adenopathy in the adult population. Pediatric specialists are less
enthusiastic about this procedure because a significant number of fine-needle
aspirations in children do not obtain tissue for appropriate pathology and
diagnostic studies (Table 9.3).
Selected Readings
Knight PJ, Mulne AF, Vaggy LE. When is lymph node biopsy indicated in children
with enlarged peripheral nodes?
Pediatrics 1982;69(4):391–396.
Peters TR, Edward KM. Cervical lymphadenopathy and adenitis. Pediatr Rev 2000;21(12)399–405.
Ridder GJ, Boedeker CC, Technau-Ihling K, et al. Role of cat-scratch disease in
lymphadenopathy in the head and neck.
Clin Infect Dis 2002;35(6):643–649.
Serour F, Gorenstein A, Somekh E. Needle aspiration for suppurative cervical
adenitis.
Clin Pediatr 2002;41(7):471–4744.
Tashiro N, Matsubara T, Uchida M, et al Ultrasonographic evaluation of cervical
lymph nodes in Kawasaki disease.
Pediatrics 2002;09(5):E77.
Twist CJ, Link MP. Assessment of lymphadenopathy in children. Pediatr Clin North Am 2002;49(5):
1009–1025.
Pictures
Book Source Details
- Book Title: Pediatric Infectious Disease
- Author(s): Donald Janner MD
- Year of Publication: 2004
- Copyright Details: Pediatric Infectious Disease, Copyright © 2004 Lippincott Williams & Wilkins.
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More About This Book:
Title: Pediatric Infectious Disease
Authors: Donald Janner MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 0-7817-5584-0
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