Lymphadenitis, Emergency Medicine

Basics

Description

Lymph nodes may be swollen and tender as part of the systemic response to infection:
- Become engorged with lymphocytes and macrophages
- May be primarily infected
- Infection in distal extremity may result in painful tender adenopathy proximally
Acute suppurative lymphadenitis may occur after pharyngeal or skin infection

Etiology

Most frequently caused by bacterial infection
Most common organisms in pyogenic lymphadenitis:
- Staphylococcus aureus " ”including resistant strains such as community-associated methicillin-resistant S. aureus (CA-MRSA):
  - CA-MRSA risk factors include prior MRSA infection, household contact of CA-MRSA patient, military personnel, incarcerated persons, athletes in contact sports, IV drug users, men who have sex with men
  - Different antibiotic susceptibility than nosocomial MRSA
  - CA-MRSA now sufficiently prevalent to warrant coverage in empiric treatment
  - Suspect CA-MRSA in unresponsive infections
- Group A ˇ ²-hemolytic Streptococcus
Cervical lymphadenitis:
- Usually pharyngeal or periodontal process
- Streptococcus and anaerobes
Axillary lymphadenitis:
- Streptococcus pyogenes (group A ˇ ²-hemolytic Streptococcus)
Nosocomial MRSA:
- Risk factors: Recent hospital or long-term care admission, surgery, injection drug use, vascular catheter, dialysis, recent antibiotic use, unresponsive infection
- Resistant to most antibiotics (see "Treatment " ¯)

Acute unilateral cervical suppurative lymphadenitis:
- Most common at age <6 yr
- Group A Streptococcus, S. aureus, and anaerobes are most common causes

Diagnosis

Signs and Symptoms

Painful swelling, inflammation/infection of lymph nodes
Commonly presents simultaneously with acute cellulitis or abscess if pyogenic cause
Axillary lymphadenitis:
- Fever, axillary pain, and acute lymphedema of arms and chest, without features of cellulitis or lymphangitis; ipsilateral pleural effusion may be present

History

Occupation
Exposure to pets
Sexual behavior
Drug use
Travel history
Associated symptoms:
- Sore throat
- Cough
- Fever
- Night sweats
- Fatigue
- Weight loss
- Pain in nodes
Duration of lymphadenopathy

Physical Exam

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 node
Skin lesions
Splenomegaly
Enlargement of supraclavicular or scalene nodes is always abnormal

Essential Workup

Acute regional lymphadenitis is clinical diagnosis, often part of larger syndrome (cellulitis)
History and physical exam to reveal infectious source

Diagnosis Tests & Interpretation

Lab

WBC is not essential:
- Possible leukocytosis with left shift or normal
CBC, Epstein " “Barr virus (EBV), cytomegalovirus (CMV), HIV, and other serologies based on clinical findings

Imaging
US or CT in patients who do not improve or progress to suppuration ‚
Diagnostic Procedures/Surgery
Consider percutaneous needle aspiration or surgical drainage in patients who do not improve or progress to suppuration ‚

Differential Diagnosis

Common infections:
- Adenovirus
- Scarlet fever
- Cat scratch disease
- Fungal
- Herpes zoster
Unusual infections:
- Sporotrichosis (rose thorns)
- Diphtheria
- West Nile fever
- Plague
- Anthrax
- Typhoid
- Rubella
Venereal infections:
- Syphilis
- Genital herpes
- Chancroid
- Lymphogranuloma venereum
Other systematic infections causing generalized lymphadenitis:
- HIV
- Infectious mononucleosis (EBV or CMV)
- Toxoplasmosis
- Tuberculosis
- Infectious hepatitis
- Dengue
Drug reaction:
- Phenytoin
- Allopurinol
Silicone implants
Malignancy
Rheumatologic disorders
Systemic lupus erythematosus
Sarcoidosis
Amyloidosis
Serum sickness

Kawasaki disease
PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis)

Treatment

Initial Stabilization/Therapy

Ensure airway, breathing, and circulation management and hemodynamic stability ‚

Ed Treatment/Procedures

General principles:
- Antibiotics based on involved primary organ/suspected pathogen (see also "Cellulitis " ¯)
- Consider local prevalence of MRSA and other resistant pathogens in addition to usual causes
- Usual outpatient treatment: 7 " “10 days
- Elevation
- Application of moist heat
- Analgesics
Drainage of abscesses if present:
- Obtain culture if drainage performed, especially to help identify resistant pathogens
Skin origin:
- Outpatient:
  - Oral cephalexin plus trimethoprim/sulfamethoxazole (TMP/SMX) (to cover CA-MRSA)
  - Alternatives to cephalexin: Oral dicloxacillin, macrolide, or levofloxacin
  - Alternatives to TMP/SMX: Clindamycin or doxycycline
- Inpatient:
  - IV nafcillin or equivalent, plus IV vancomycin (to cover CA-MRSA)
Pharyngeal or periodontal origin:
- Outpatient:
  - Oral penicillin VK
  - Alternatives: Oral clindamycin or amoxicillin/clavulanate
- Inpatient:
  - IV penicillin G (aqueous) and IV metronidazole
  - Alternatives: IV ampicillin/sulbactam or IV clindamycin
Axillary lymphadenitis:
- Outpatient:
  - Oral penicillin VK
  - Alternatives: Oral macrolide or amoxicillin/clavulanate
- Inpatient:
  - IV penicillin G (aqueous)
  - Alternatives: IV ampicillin/sulbactam
Acute unilateral cervical suppurative lymphadenitis:
- Outpatient:
  - Oral penicillin VK
  - Alternatives: Oral clindamycin or amoxicillin/clavulanate
MRSA:
- Nosocomial MRSA:
  - IV vancomycin or PO or IV linezolid
- CA-MRSA:
  - PO: TMP/SMX, clindamycin or doxycycline
  - IV: Vancomycin or clindamycin

Medication

Amoxicillin/clavulanate: 500 " “875 mg (peds: 45 mg/kg/24 h) PO BID or 250 " “500 mg (peds: 40 mg/kg/24 h) PO TID
Ampicillin/sulbactam: 1.5 " “3 g (peds: 100 " “300 mg/kg/24 h up to 40 kg; >40 kg, give adult dose) IV q6h
Cephalexin: 500 mg (peds: 50 " “100 mg/kg/24 h) PO QID
Clindamycin: 450 " “900 mg (peds: 20 " “40 mg/kg/24 h) PO or IV q6h
Dicloxacillin: 125 " “500 mg (peds: 12.5 " “25 mg/kg/24 h) PO q6h
Doxycycline: 100 mg PO BID for adults
Erythromycin base: (adult) 250 " “500 mg PO QID
Linezolid: 600 mg PO or IV q12h (peds: 30 mg/kg/d divided q8h)
Metronidazole: (adult) 15 mg/kg IV once, followed by 7.5 mg/kg IV q6h
Nafcillin: 1 " “2 g IV q4h (peds: 50 " “100 mg/kg/24 h divided q6h); max. 12 g/24 h
Penicillin VK: 250 " “500 mg (peds: 25 " “50 mg/kg/24 h) PO q6h
Penicillin G (aqueous): 4 mIU (peds: 100,000 " “400,000 U/kg/24 h) IV q4h
Rifampin: 600 mg PO BID for adults
TMP/SMX: 2 DS tabs PO q12h (peds: 6 " “10 mg/kg/24 h TMP divided q12h)
Vancomycin: 1 g IV q12h (peds: 10 mg/kg IV q6h, dosing adjustments required age <5 yr); check serum levels

Follow-Up

Disposition

Admission Criteria

Toxic appearing
History of immune suppression
Concurrent chronic medical illnesses
Unable to take oral medications
Unreliable patients

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 may be helpful in the following circumstances:
- 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

Pearls and Pitfalls

Staph species are the most common cause of acute regional lymphadenitis due to pyogenic bacteria
Empiric antibiotic coverage must extend to include CA-MRSA, in addition to coverage for other staph species and strep

Additional Reading

Abrahamian ‚ FM, Talan ‚ DA, Moran ‚ GJ. Management of skin and soft-tissue infections in the emergency department. Infect Dis Clin North Am. 2008;22:89 " “116.
Boyce ‚ JM. Severe streptococcal axillary lymphadenitis. N Engl J Med. 1990;323:655 " “658.
Henry PH, Longo DL. Enlargement of lymph nodes and spleen. In: Longo ‚ DL, Kasper ‚ DL, Jameson ‚ JL, et al., eds. Harrisons Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill;2012:465 " “471.
Pasternack ‚ MS, Swartz ‚ MN.Lymphadenitis and lymphangitis. In: Mandell ‚ GL, Bennett ‚ JE, Dolin ‚ R, eds. Mandell, Douglas and Bennett's Principlesand Practice of Infectious Diseases. 7th ed. New York, NY: Elsevier/ChurchillLivingstone; 2010:1323 " “1333.
Thomas ‚ KT, Feder ‚ HM Jr, Lawton ‚ AR, et al. Periodic fever syndrome in children. JPediatr. 1999;135:15 " “21.

Codes

ICD9

289.1 Chronic lymphadenitis
289.3 Lymphadenitis, unspecified, except mesenteric
683 Acute lymphadenitis

ICD10

I88.9 Nonspecific lymphadenitis, unspecified
L04.0 Acute lymphadenitis of face, head and neck
L04.2 Acute lymphadenitis of upper limb
L04.3 Acute lymphadenitis of lower limb
I88.1 Chronic lymphadenitis, except mesenteric
L04.1 Acute lymphadenitis of trunk
L04.8 Acute lymphadenitis of other sites
L04.9 Acute lymphadenitis, unspecified
L04 Acute lymphadenitis

SNOMED

19471005 Lymphadenitis (disorder)
3502005 cervical lymphadenitis (disorder)
200698001 acute lymphadenitis of upper limb (disorder)
200699009 acute lymphadenitis of lower limb (disorder)
32035007 Chronic lymphadenitis (disorder)

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