Clinical Practice Guidelines

Cervical Lymphadenopathy

  • Enlargement of the cervical lymph nodes commonly occurs with viral infections. These "reactive" nodes are usually small, firm and non-tender and they may persist for weeks to months.

    Causes of Cervical Lymphadenopathy

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    Acute bacterial adenitis is characterised by larger nodes >10mm, which are tender and may be fluctuant. Most typically these are in the anterior part of the neck. There is often associated fever and warm, erythematous overlying skin. The majority are caused by Staphylococcus Aureus or Group A Streptococcus (Strep pyogenes). A site of entry may be found e.g. mouth or scalp. Anaerobic bacteria may be associated with dental disease in older children.

    Also consider Kawasaki Disease - unilateral, >15mm, painful nodes and other associated features.

    Persistent enlargement of lymph nodes (> 2 weeks) may be caused by a number of other conditions:

    Atopic Eczema

    • Significant persistent enalargement may be associated with atopic eczema. These nodes are often more prominent in the posterior part of the neck and are usually bilateral.

    Infections

    • Infectious mononucleosis (EBV), cytomegalovirus - may have generalised lymphadenopathy and hepatosplenomegaly.
    • Mycobacterium avium complex - Adenoapthy is usually unilateral and most cases occur in the under 5-year age group. Non-tender, slightly fluctuant node, which may become tethered to underlying structures. Violaceous hue to the overlying skin is sometimes seen. Systemically well. Usually not immunocompromised.
    • Mycobacterium tuberculosis - non-tender nodes. History of exposure. Systemic symptoms of fever, malaise, weight loss.
    • Cat Scratch Disease (Bartonella henselae) - tender, usually axillary, nodes. History of a cat scratch or lick 2 weeks prior. There may be a papule at the site.
    • Toxoplasma gondii - generalised lymphadenopathy. Systemic features of fatigue or myalgia.
    • HIV

    Malignancy

    • Lymphoma - Hodgkins, Non-Hodgkins
    • Leukaemia - ALL, AML, CML,

    Rheumatologic conditions

    • Juvenile chronic arthritis
    • SLE

    Management of Acute Adenitis

    Fluctuant Node

    • Incision and drainage (contraindicated in suspected TB as may result in sinus formation)

    Well - oral antibiotics for 10 days, with review in 48 hours.

    • Flucloxacillin 25 mg/kg QID

      Hypersensitivity to penicillin: Cephalexin 25 mg/kg (up to 500mg) TDS
      Severe penicillin hypersensitivity: Erythromycin 15 mg/kg (up to 500mg) TDS

    Neonates, unwell or failed oral Rx - IV antibiotics

    • Flucloxacillin 50 mg/kg up to 2 g 6-hourly

      Hypersensitive to penicillin: Cephazolin 25 mg/kg up to 2g IV 6 hourly
      Severe penicillin hypersensitivity: Clindamycin 10mg/kg up to 450mg 6hourly

    Investigations

    Acute adenitis

    • No blood investigations
    • MCS if incision and drainage

    Persisting adenitis (>2 weeks) - consider the following

    • FBE/film
    • Serology - EBV, CMV, HIV, Toxoplasmosis, Cat scratch
    • Mantoux test
    • CXR
    • CT may be required preoperatively
    • Excision biopsy