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Cervical Adenitis, Emergency Medicine

Basics

Description

- 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

- 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

- 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

- 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)

- 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

- 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)

- 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

  • Acute bacterial infection of a cervical lymph nodeOften 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 nodesJugulodigastric node located just below the angle of the mandible is common siteCervical nodes act as the final common pathway for lymphatic drainage of all areas of the head and neckInitial lymphadenopathy results after bacterial invasion of regional areas of the head and neckLocal lymph nodes swell secondary to hyperplasia of sinusoidal cells and infiltration of lymphocytesIf 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 infectionClinically manifests as warm, tender, swollen, erythematous node

Etiology

  • ~70% of cases are a result of group A β-hemolytic Streptococcal infection20% Staphylococcal infection10% 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 lymphadenitisRarely seenUsually a chronic lymphadenitis in the posterior cervical nodesPurified protein derivative (PPD) is usually strongly reactiveTreatment is nonsurgical
  • Atypical mycobacteria (nontuberculous) Mycobacterium avium complex:More commonly seenUsually a chronic lymphadenitis in the submandibular or anterior cervical nodesPPD test results are unreliableTreatment is primarily surgical
  • Bartonella henselae (catscratch disease):Subacute lymphadenitisFever and mild systemic symptoms occur in only ~3% of patientsHas 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 bacilliYersinia pestisGroup B streptococcusFrancisella tularensisAlpha-streptococcusAnthrax
  • 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 media94% 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 abscessOtitis media, otitis externaDental infectionImpetigo, 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 PPDLook 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 differentialMonospotThroat culturesAntibody 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 infectionChest 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 nonspecificCan identify deep-cavity abscess if not palpable on exam
  • Excisional biopsy

Diagnostic Procedures/Surgery

  • Needle aspiration:All fluctuant nodes should be aspiratedSend for Gram stain and acid-fast stains, aerobic and anaerobic cultures, mycobacteria, and fungiIf 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, CMVMumps, rubella, rubeola
  • Specific pediatric diseases with cervical adenitis in their diagnostic criteria:Kawasaki diseaseKikuchi diseasePeriodic 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 carcinomaRare cause of a nonspecific lump in children (<2% overall)
  • Other systemic diseases:

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. aureusConsider MRSA if symptoms not improving on standard antibiotic therapy
  • Aspirate all fluctuant nodes
  • Many oral antibiotics are effective:CephalexinCefadroxilAmoxicillin/clavulanic acid
  • Patients with suspected dental, periodontal, or anaerobic causes of illness:ClindamycinAmoxicillin/clavulanic acid
  • CA-MRSA:Clindamycin (many isolates are now resistant)BactrimVancomycin 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 worsenAbscess developsVoice changesDyspnea developsSystemic 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

See Also (Topic, Algorithm, Electronic Media Element)

  • Kawasaki Disease
  • Lymphadenitis

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