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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

- 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

- Extent of lymphadenopathy (localized or generalized) - Size of nodes: - Abnormal size by site: - General: >1 cm - Epitrochlear: >0.5 cm - Inguinal: >1.5 cm

- 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

- 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

  • Lymph nodes may be swollen and tender as part of the systemic response to infection:Become engorged with lymphocytes and macrophagesMay be primarily infectedInfection 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 menDifferent antibiotic susceptibility than nosocomial MRSACA-MRSA now sufficiently prevalent to warrant coverage in empiric treatmentSuspect CA-MRSA in unresponsive infectionsGroup A ˇ ²-hemolytic Streptococcus
  • Cervical lymphadenitis:Usually pharyngeal or periodontal processStreptococcus 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 infectionResistant to most antibiotics (see "Treatment " ¯)
  • Acute unilateral cervical suppurative lymphadenitis:Most common at age <6 yrGroup 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 throatCoughFeverNight sweatsFatigueWeight lossPain in nodes
  • Duration of lymphadenopathy

Physical Exam

  • Extent of lymphadenopathy (localized or generalized)
  • Size of nodes:Abnormal size by site:General: >1 cmEpitrochlear: >0.5 cmInguinal: >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:AdenovirusScarlet feverCat scratch diseaseFungalHerpes zoster
  • Unusual infections:Sporotrichosis (rose thorns)DiphtheriaWest Nile feverPlagueAnthraxTyphoidRubella
  • Venereal infections:SyphilisGenital herpesChancroidLymphogranuloma venereum
  • Other systematic infections causing generalized lymphadenitis:HIVInfectious mononucleosis (EBV or CMV)ToxoplasmosisTuberculosisInfectious hepatitisDengue
  • Drug reaction:
  • 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 causesUsual outpatient treatment: 7 " “10 daysElevationApplication of moist heatAnalgesics
  • 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 levofloxacinAlternatives to TMP/SMX: Clindamycin or doxycyclineInpatient:IV nafcillin or equivalent, plus IV vancomycin (to cover CA-MRSA)
  • Pharyngeal or periodontal origin:Outpatient:Oral penicillin VKAlternatives: Oral clindamycin or amoxicillin/clavulanateInpatient:IV penicillin G (aqueous) and IV metronidazoleAlternatives: IV ampicillin/sulbactam or IV clindamycin
  • Axillary lymphadenitis:Outpatient:Oral penicillin VKAlternatives: Oral macrolide or amoxicillin/clavulanateInpatient:IV penicillin G (aqueous)Alternatives: IV ampicillin/sulbactam
  • Acute unilateral cervical suppurative lymphadenitis:Outpatient:Oral penicillin VKAlternatives: Oral clindamycin or amoxicillin/clavulanate
  • MRSA:Nosocomial MRSA:IV vancomycin or PO or IV linezolidCA-MRSA:PO: TMP/SMX, clindamycin or doxycyclineIV: 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 malignancyLymph node size >1 cmSupraclavicular 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Cellulitis
  • Lymphangitis
  • MRSA

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)