Lymphadenitis

Not to be confused with lymphangitis.

Background

• Lymphadenitis = inflammation of lymph node
• Can be single or multiple
• Most commonly due to viral or bacterial disease (usually staph or strep) infection local to region draining lymph to that node
• Pyogenic organisms may cause suppurative infection/abscess
• Not to be confused with lymphangitis

Clinical Features

Tuberculosis lymphadenitis: diffuse swelling in left submandibular region.

• Pain
• Erythema
• Enlargement over time
• Associated symptoms:
  • Fever
  • Local signs of infection depending on location of lymph node
    • Cervical
      • URI symptoms
      • Conjunctivitis
      • Mouth sores, dental infection
    • Axillary
      • Breast infections
      • Upper-limb infections
    • Mesenteric
      • Abdominal pain, nausea/vomiting
    • Inguinal
      • GU infections
      • Lower-limb infections

Differential Diagnosis

Lymphadenitis

Infectious

• Reactive adenitis
• Bacterial lymphadenitis
• Tuberculous lymphadenitis
• Cellulitis
• Cat-scratch disease
• Parotitis
  • Suppurative parotitis
  • Viral parotitis
• Lymphangitis
• Toxoplasmosis
• Tularemia
• Viral disease
  • HIV-AIDS
  • Cytomegalovirus
  • Epstein-Barr Virus
• Fungal disease
• Reactive adenitis

Non-Infectious

• Malignancy
  • Lymphoma
  • Metastatic cancer
• Rheumatologic Disease
  • Kawasaki Disease
  • Systemic lupus erythematosus
  • Sarcoidosis
  • Juvenile Idiopathic Arthritis
  • Langerhans Cell Histiocytosis
• Cutaneous Lesions:
  • Bacillary angiomatosis
  • Purpura
  • Hematomas
  • Angiomas
  • Dermatofibromas
  • Nevi
• Drug reaction
  • Phenytoin or Carbamazepine
• Postvaccination
• Sarcoidosis
• Salivary gland diagnoses

Evaluation

• Usually clinical diagnosis
• If associated exudative pharyngitis, consider Rapid GAS testing
• If severe symptoms (ill-appearing, high fever), consider:
  • Basic labs (CBC, BMP)
  • Blood cultures
  • ESR/CRP may be helpful for monitoring course of infection/response to treatment
  • Ultrasound to evaluate for associate abscess or deep locations
• If subacute/chronic, consider:
  • CBC, BMP, ESR/CRP
  • Uric acid, LDH
  • Tuberculin skin test

Management

• Mild symptoms (well appearing, absent/low-grade fever, minimal tenderness)
  • Serial exams, PMD follow-up
  • PO Antibiotic treatment if associated GAS pharyngitis found
• Moderate symptoms (fever, tenderness without fluctuance)
  • Empiric PO Antibiotic therapy that covers S. Aureus and GAS
    • Cephalexin 500 mg PO QID x 10 days
    • Amoxicillin-Clavulanate 875 mg PO BID x 10 days
    • Clindamycin 300-450 mg PO TID x 10 days
  • Consider anaerobic coverage if found to have poor dentition or evidence of periodontal disease
• Severe symptoms (ill-appearing, fever, fluctuance or overlying cellulitis)
  • Incision & Drainage or Needle Aspiration
  • IV Antibiotics

Disposition

• Generally can be discharged with outpatient follow-up/treatment if mild/moderate symptoms
• Admit for:
  • Sepsis/Severe symptoms requiring I&D or IV antibiotics
  • Failure of outpatient treatment

References

• Dulin MF, Kennard TP, Leach L, Williams R. Management of cervical lymphadenitis in children. Am Fam Physician 2008; 78:1097.