Lymphadenopathy

Lymphadenopathy is defined as enlargement of lymph nodes and when infllammation occurs within the node it is called lymphadenitis.  This is a common pediatric problem and the presence of an enlarged gland is a common presenting complaint in pediatrician's offices.  A careful history and physical examination will usually help in making the diagnosis of the etiology of the lymphadenopathy. 

Pertinent questions that should be asked.

  1. H as the patient been ill?
  2. Are there symptoms of a sore throat, difficulty swallowing, drooling?
  3. Has there been any rashes or skin lesions in the drainage area of the node?
  4. Has there been any exposure to cats, pets, wild animals, raw or undercooked meat?
  5. Has the family traveled?
  6. Has there been any exposure to TB?
  7. Is the child on any medications?
  8. What is the status of the child's teeth?
  9. Has there been many previous infections suggestive of an immunologic defieciency syndrome?
  10. How long has the node been noticeably enlarged?
  11. Has there been a recent viral illness?
  12. Has the child had a recent immunization?
Physical findings helpful in making diagnosis
  1. Size of the node- less than 10 mm. usually okay except in inguinal area where normal enlarged nodes may be 15 mm.
  2. Most "benign" nodes are mobile, discrete, and nontender.
  3. Presence of enlarged liver and spleen.
  4. Evidence of pallor, petechiae, jaundice, bruising.
  5. Evidence of red throat with exudate.
  6. Rash, sores, or eczema.
  7. Presence of multiple nodes in other areas.
  8. Unilateral cervical adenopathy often due to lymphadenitis while bilateral due to viral or strep pharyngitis.
Common infectious etiology of enlarged nodes.
  1. Adenovirus
  2. CMV
  3. Enterovirus
  4. EBV
  5. Varicella
  6. Herpes simplex
  7. Staphlococcus infection
  8. Group A hemolytic Streptococcus
  9. Cat Scratch Disease-Bartonella henselae
  10. Tularemia
  11. Brucellocis
Common non-infectious causes of lymphadenopathy
  1. Hodgkin's disease
  2. Lymphomas
  3. Leukemia
  4. Metastatic disease
  5. Histiocytosis
  6. SLE and JRA
  7. Kawasaki Disease
Common simulators of lymphadenopathy
  1. Lipomas
  2. Branchial cleft cysts
  3. Cystic hygromas
  4. Salivary glands
  5. Thyroglossal duct cysts- usually in the midline
     The common approach to the otherwise healthy child with unilateral cervical lymph node enlargement with no other physical findings is to treat as a bacterial infection to cover Group A Streptococcus  and Staphylococcus aureus.  The patient may apply heat to the area and Augmentin , Erythromycin, and Keflex will cover the common pathogens. The patient should be rechecked in a few days. If it continues to enlarge and becomes fluctuant and there is evidence of cellulitis of the skin, surgical referral may be needed to perform I&D. If it is not getting larger, may stay prominent for weeks and no further treatment necessary. 
     Bilateral cervical enlargement most often secondary to strep phayngitis or EBV in the older child. Throat culture is recommended and if the child does not improve, further evaluation necessary.

Other diagnostic workup would include

  1. CBC and diff and platelet count.
  2. Test for EBV
  3. PPD
  4. Chest x-ray
  5. Possibly serologic test to further define possible viral etiologies
  6. Ultrasound- may help indicate the presence of purulent material to drain
Failure of improvement after evaluation, continued enlarging, matting, and other physical and constitutional signs, may necessitate a biopsy for diagnosis.

References

  1. Chesney, R.J. Cervical Lymphadenopathy Pediatrics in Review. 1994 Vol 15, pg. 276.
  2. Kelly CS and Kelly RE. Lymphadenopathy in Children. Pediatric Clinics of North America. 1998; 45(4):875-888.
  3. Margileh, Andrew. Contemporary Pediatrics. Jan 1995 Vol 12 No.1 pgs.23-42.
  4. Peters, timothy and Edwards, Kathyrn.  Cervical Lymphadenopathy and Adenitis. Pediatrics in Review December 2000