Diagnosis
-H&P: Review meds for culprits.
-Risk factors for cancer:
-R/o palpable popliteal, iliac, and supraclavicular nodes which are always abnormal. Evaluate for palpable epitrochlear nodes greater than 5 mm which would be abnormal as well.
DDx & Causes.
–Ultrasonography: Initial imaging modality for children up to 14 years per ACR
–CT: The initial imaging modality for children older than 14 years per ACR.
-Localized LN: Consider observing for about 4 weeks if cancer is very low in the ddx based on H&P.
-Generalized LN: CBC + manual diff, RPR, PPD, HIV test, HBsAg, and ANA ( to r/o infectious and autoimmune causes).
-FNA
Treatment
-Treatment based on cause.
-Acute unilateral anterior cervical lymphadenitis with systemic symptoms in children: Consider empiric antibiotics that target Staphylococcus aureus and group A streptococci. Options: Oral cephalosporins, amoxicillin/clavulanate (Augmentin), clindamycin.
-“Avoided steroids until a definitive diagnosis is made because treatment could potentially mask or delay histologic diagnosis of leukemia or lymphoma”.
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—– ABFM Board Question
Cervical Lymphadenopathy
A mother brings her 5-year-old daughter to see you because she found a mass in the child’s neck. The mass appeared over the past week and was preceded by a sore throat. Her pharyngitis is now resolved but she still has a fever, although it is not as high. The mother is most concerned because the mass developed over a short span of time, and it is warm, red, and tender. When asked, she says that her daughter has had no recent exposure to cats. When you examine the child you note that her temperature is 38.0°C (100.4°F). You also find shotty adenopathy in both anterior cervical lymph node chains, and a 2.5-cm warm, firm, moderately tender lymph node in the right anterior cervical chain. The overlying skin is also erythematous. Which one of the following would be the most appropriate management at this time?
Ultrasonography of the neck mass
CT with intravenous contrast of the neck mass
Ultrasound-guided fine-needle aspiration of the mass
Immediate referral to a head and neck surgeon
Empiric antibiotic therapy with observation for 4 weeks
Rationale:
This child has cervical lymphadenitis, characterized by systemic symptoms, unilateral lymphadenopathy, skin erythema, node tenderness, and a node that is 2–3 cm in size. The most common organisms associated with lymphadenitis are Staphylococcus aureus and group A Streptococcus. Empiric antibiotic therapy with observation for 4 weeks is acceptable for children with presumed reactive lymphadenopathy (SOR C). If symptoms do not resolve, or if the mass increases in size during antibiotic treatment, further evaluation is appropriate. When imaging is indicated, ultrasonography is the preferred initial study for most children with a neck mass. CT with intravenous contrast media is the preferred study for evaluating a malignancy or a suspected retropharyngeal or deep neck abscess that may require surgical drainage. If the initial mass is suspicious for malignancy (>3.0 cm in size, hard, firm, immobile, and accompanied by type B symptoms such as fever, malaise, weight loss, or night sweats) immediate referral to a surgeon for evaluation and possible biopsy is appropriate.
Resources:
- Unexplained Lymphadenopathy: Evaluation and Differential Diagnosis, AAFP, http://www.aafp.org/afp/2016/1201/p896.html
- Evaluation and Management of Neck Masses in Children, AAFP, http://www.aafp.org/afp/2014/0301/p353.html
- http://www.aafp.org/afp/2002/1201/p2103.html