Cervical Adenitis, Emergency Medicine

Basics

Description

Acute bacterial infection of a cervical lymph node
- Often arising after a prior bacterial infection of the head or neck area
Primarily a pediatric disease:
- Becoming more common in adults owing to immunocompromised disease states (HIV, cancer, transplant patients)
Any cervical node can become infected:
- >80% of childhood cervical lymphadenitis involves the submandibular or deep cervical nodes
- Jugulodigastric node located just below the angle of the mandible is common site
- Cervical nodes act as the final common pathway for lymphatic drainage of all areas of the head and neck
- Initial lymphadenopathy results after bacterial invasion of regional areas of the head and neck
- Local lymph nodes swell secondary to hyperplasia of sinusoidal cells and infiltration of lymphocytes
- If the infection is not contained, the bacteria enter the lymph system and proliferate (lymphadenitis)
- Pus forms when neutrophils are incited, and an abscess develops when host defenses are unable to clear infection
- Clinically manifests as warm, tender, swollen, erythematous node

Etiology

~70% of cases are a result of group A β-hemolytic Streptococcal infection
- 20% Staphylococcal infection
- 10% related to viral infection or other bacteria
Infections secondary to community-acquired MRSA (CA-MRSA) have increased in frequency
Children have one of the highest rate of CA-MRSA colonization and invasive disease
Mycobacteria TB:
- Scrofula or tuberculous lymphadenitis
- Rarely seen
- Usually a chronic lymphadenitis in the posterior cervical nodes
- Purified protein derivative (PPD) is usually strongly reactive
- Treatment is nonsurgical
Atypical mycobacteria (nontuberculous) Mycobacterium avium complex:
- More commonly seen
- Usually a chronic lymphadenitis in the submandibular or anterior cervical nodes
- PPD test results are unreliable
- Treatment is primarily surgical
Bartonella henselae (catscratch disease):
- Subacute lymphadenitis
- Fever and mild systemic symptoms occur in only ~3% of patients
- Has indolent course but usually spontaneously resolves after 4-6 wk
Anaerobes:
- Consider when associated with infections of the teeth or gingiva
Rare organisms:
- Gram-negative bacilli
- Yersinia pestis
- Group B streptococcus
- Francisella tularensis
- Alpha-streptococcus
- Anthrax

One of the most common causes of a neck mass in a child
Overall, group A Streptococcus and Staphylococcus aureus most common causes
In neonates, group B Streptococcus and S. aureus most common
Group B Streptococcal cellulitis-adenitis syndrome:
- Infants are usually 3-7 wk of age, male, febrile, with submandibular or facial cellulitis, and an ipsilateral otitis media
- 94% incidence of concurrent bacteremia
S. aureus associated with more indolent course and higher frequency of suppuration
Viral infections generally result in bilateral lymphadenopathy

Consider malignancy over infection in this population, especially in the absence of fever, leukocytosis, etc.
Fixed, nontender, hard node most likely not cervical adenitis

Diagnosis

Signs and Symptoms

Enlarged, tender cervical lymph node
Usually unilateral and solitary
Warmth and erythema of overlying skin
Early in course, node is firm but may become fluctuant later
With or without fever
Malaise
Irritability in infants and children
Usually a concurrent head and neck infection:
- Pharyngitis, tonsillitis, peritonsillar abscess
- Otitis media, otitis externa
- Dental infection
- Impetigo, scalp infection

History

Time of onset of symptoms
Associated symptoms: Fever, weight loss, rash
Exposures/travel history
Comorbidities/birth history for infants

Physical Exam
Complete evaluation of head and neck with attention to airway and patients clinical appearance

Essential Workup

Cervical adenitis is a clinical diagnosis
Identify primary source of infection in head and neck area (e.g., otitis media, tonsillitis)
If no primary inflammatory source of infection in head and neck:
- Address possible TB exposure with PPD
- Look for signs of systemic disease and viral illness

Diagnosis Tests & Interpretation

Lab

Unnecessary if a treatable primary source of infection confirmed
Blood cultures for toxic-appearing patients
Sepsis workup in neonates
If cause unclear, the following lab tests may help to discern a nonbacterial cause (see "Differential Diagnosis"):
- Leukocyte count with differential
- Monospot
- Throat cultures
- Antibody titers (Epstein-Barr virus, CMV, toxoplasmosis)

Imaging

CXR study, lateral neck, or Panorex:
- Helpful if source of infection unclear or to rule out a deep space infection
- Chest radiograph study to screen for TB
CT or MRI of neck:
- Helpful to exclude deep space infections or delineating embryonic developmental masses
US:
- Can differentiate cystic from solid structures, but other findings nonspecific
- Can identify deep-cavity abscess if not palpable on exam
Excisional biopsy

Diagnostic Procedures/Surgery

Needle aspiration:
- All fluctuant nodes should be aspirated
- Send for Gram stain and acid-fast stains, aerobic and anaerobic cultures, mycobacteria, and fungi
- If any suspicion of tuberculous lymphadenitis, the node should not be aspirated owing to risk for sinus development and chronic drainage
Intradermal skin testing:
- Mycobacteria, catscratch disease

Differential Diagnosis

Lymphadenopathy (inflammation of node but no bacterial infection) can be a sign of many systemic diseases; usually these nodes are multiple and bilateral
Viral infections are a common cause:
- Respiratory viruses (adenoviruses, rhinoviruses, enteroviruses)
- Epstein-Barr virus, herpes simplex virus, varicella-zoster virus, CMV
- Mumps, rubella, rubeola
Specific pediatric diseases with cervical adenitis in their diagnostic criteria:
- Kawasaki disease
- Kikuchi disease
- Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis known by mnemonic PFAPA (seen in preschool-aged children)
Toxoplasmosis
Congenital cysts:
- Brachial cleft cysts, thyroglossal duct cysts, cystic hygromas
Malignancies:
- Leukemia, lymphoma, rhabdomyosarcoma, thyroid carcinoma
- Rare cause of a nonspecific lump in children (<2% overall)
Other systemic diseases:
- Lupus, sarcoidosis

Treatment

Initial Stabilization/Therapy

Oxygen, monitor airway for any signs of compromise
Universal precautions

Ed Treatment/Procedures

Treatment directed toward the primary source of infection in the head and neck:
- If unsure of cause, treat for group A Streptococcus and S. aureus
- Consider MRSA if symptoms not improving on standard antibiotic therapy
Aspirate all fluctuant nodes
Many oral antibiotics are effective:
- Cephalexin
- Cefadroxil
- Amoxicillin/clavulanic acid
Patients with suspected dental, periodontal, or anaerobic causes of illness:
- Clindamycin
- Amoxicillin/clavulanic acid
CA-MRSA:
- Clindamycin (many isolates are now resistant)
- Bactrim
- Vancomycin or Linezolid if toxic and requiring inpatient care
Treatment should be for at least 10 days, even if symptoms resolve sooner
Warm, moist compresses
Analgesics, as needed

Medication

First Line

Cefadroxil: 500 mg (peds: 30 mg/kg/24 h) PO q12h
Cephalexin: 250-500 mg (peds: 25-50 mg/kg/24 h) PO q6h
Amoxicillin/clavulanic acid: 250-500 mg (peds: 20-40 mg/kg/24 h) PO q8h
Clindamycin: 300 mg (peds: 8-25 mg/kg/24 h) PO q6h
TMP-SMX (Bactrim): DS (160/800) 2 tabs PO BID (peds: 40 mg/200 mg/10 kg/PO BID)

Second Line

Cefazolin: 1-2 g (peds: 25-50 mg/kg/24 h) IV q8h
Nafcillin: 1-2 g (peds: 50-200 mg/kg/24 h) IV q4-6h
Clindamycin: 600-900 mg (peds: 20-40 mg/kg/24 h) IV q8h
Ampicillin-sulbactam: 1.5-3 g (peds: 200 mg/kg/d) q6h
Vancomycin: 10-15 mg/kg IV Q12h (peds: 40-60 mg/kg/d div q8h)
Linezolid (alternative to Vancomycin): 600 mg IV BID for children >12 or 30 mg/kg/8 h with max. dose of 1,200 mg for children <12 yr

Follow-Up

Disposition

Admission Criteria

Neonates
Airway compromise
Patient appears ill
Immunocompromised
Inability to take PO
Not improving on oral antibiotics

Discharge Criteria

Most patients can be discharged on PO antibiotics
Close follow-up with a recheck in 2-3 days
Ability to take PO antibiotics and fluids
Return to the ED if:
- Symptoms worsen
- Abscess develops
- Voice changes
- Dyspnea develops
- Systemic symptoms develop

Issues for Referral
Clinical exam concerning for malignancy or congenital abnormality (brachial cleft/thyroglossal duct cyst)

Follow-Up Recommendations

Mandatory recheck in 48 hr to ensure improvement
Referral to dentist or ENT depending on source of infection

Pearls and Pitfalls

Cervical adenitis is a clinical diagnosis
Unilateral warm, tender, swollen, erythematous lymph node
Most common bacteria responsible for infection are group A Strep and S. aureus.
Consider group B Strep in infants and MRSA for infections not improving on standard antibiotics
Disposition should be influenced by patients clinical status

Additional Reading

Hay WW, Levin MJ Jr, Deterding R, et al. CURRENT Diagnosis & Treatment: Pediatrics. 21st ed. McGraw-Hill; 2012:503.
Healy CM. Diagnostic approach to and initial treatment of cervical lymphadenitis in children. UpToDate.com/online
Healy CM, Baker CJ. Cervical lymphadenitis. In: Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL, eds. Textbook of Pediatric Infectious Diseases. 6th ed. Philadelphia, PA: Saunders; 2009:185.
Swanson D. Etiology and clinical manifestations of cervical lymphadenitis in children. UpToDate.com/online

Codes

ICD9

683 Acute lymphadenitis

ICD10

L04.0 Acute lymphadenitis of face, head and neck

SNOMED

238405002 Acute cervical adenitis (disorder)
3502005 cervical lymphadenitis (disorder)
15170009 Submandibular lymphadenitis (disorder)
240414006 Cervical atypical mycobacterial lymphadenitis
300929003 Tonsillar adenitis (disorder)
54084005 Cervical tuberculous lymphadenitis

Home

Erectile Dysfunction

Doctor123.org