AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Lymphadenitis is the inflammation and/or enlargement of a lymph node. Lymph node enlargement is common in children. Most cases represent a response to benign, local, or generalized infections (usually viral). Lymphadenitis may affect a single node or a localized group of nodes (regional adenopathy) and may be unilateral or bilateral. The onset and course of lymphadenitis may be acute, subacute, or chronic.¹

Most children with lymphadenitis exhibit small palpable cervical, axillary, and inguinal nodes. Approximately 5% of these children have palpable suboccipital or postauricular nodes. Palpable supraclavicular, epitrochlear, and popliteal nodes are uncommon, as are mediastinal or abdominal nodes that are detected with radiographic studies.

Pathophysiology

Increased node size may be caused by the following:

• Multiplication of cells within the node, including lymphocytes, plasma cells, monocytes, or histiocytes
• Infiltration of cells from outside the node, such as malignant cells or neutrophils
• Draining of a source of infection by lymph nodes

If the cause of adenopathy is not evident, consider congenital or neoplastic causes.

Frequency

United States

Lymph nodes are usually small and firm. They are palpable in the cervical, axillary, inguinal, and occipital regions of healthy infants and children. Multiple nodes, especially if present with splenomegaly, may be associated with human immunodeficiency virus (HIV) infection.

International

Tuberculous lymphadenitis can be seen in developing countries.

Mortality/Morbidity

Nodes may be large and may cause local pain and tenderness. Overlying skin may be erythematous. Neck stiffness and torticollis may occur because of cervical lymphadenopathy. Inflammation of retropharyngeal nodes (retropharyngeal abscess) may lead to dysphagia or dyspnea.

Mediastinal lymphadenitis may cause cough, dyspnea, stridor, dysphagia, pleural effusion, and venous congestion in the upper body. Intra-abdominal (mesenteric and retroperitoneal) adenopathy may manifest as abdominal pain. Iliac lymph node involvement may cause abdominal pain and limping.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Upper respiratory symptoms, sore throat, earache, coryza, conjunctivitis, and impetigo
• Fever, irritability, and anorexia
• Contact with animals, especially kittens
• Dental care: Submaxillary adenopathy may develop secondary to stomatitis, dental caries, or a dental abscess.
• Risk factors for tuberculosis²
• • Generalized lymphadenopathy in a child with tuberculosis may indicate a hematogenous spread of tubercle bacilli.
  • Localized involvement is most common in the mediastinal, mesenteric, or anterior cervical nodes.
• Acute or chronic onset
• • Usually, bilateral acute cervical adenitis is caused by either viral pharyngitis or infectious mononucleosis.
  • Chronic localized adenopathy can be attributed to a persistent regional infection.
• Skin and scalp conditions: Occipital and postauricular adenopathy may accompany scalp infections, seborrheic dermatitis, or scalp pediculosis. Epitrochlear and axillary lymphadenopathy may result from infections on the arms. Inguinal and femoral adenopathy may be due to infections on the lower extremities.
• Periodicity: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome usually results in adenopathy associated with the other findings every 3-6 weeks.
• History of travel: When adenopathy is caused by Yersinia pestis (bubonic plague), the patient may have visited a rural area in the western United States one week prior to the onset of illness.
• Medication use
• • Hydantoin
  • Mesantoin
• Age: Atypical mycobacteria typically cause adenopathy in toddlers.

Physical

• Location
• • Tularemia may be accompanied by regional adenopathy, most commonly cervical.
  • Yersinia enterocolitica infection may cause cervical or abdominal adenopathy.
  • Salmonella infections may accompany generalized lymphadenopathy.
  • Rubella and parvovirus infection is characterized by enlarged and tender posterior auricular, posterior cervical, and occipital lymph nodes.
  • Atypical (environmental) mycobacteria may cause submandibular or submental adenopathy.
  • Mediastinal or infectious hilar adenopathy may occur in patients with tuberculosis, chronic sinusitis, histoplasmosis, tularemia, infectious mononucleosis, candidiasis, coccidioidomycosis, and bronchiectasis.
• Size: Lymph nodes that are noted to increase rapidly in size may indicate potential malignancy.
• Shape: Confluent lymph nodes may be indicators of malignancy.
• Consistency
• • Descriptors may include soft, fluctuant, firm, rubbery, or hard.
  • In early stages, nodes in tuberculosis are well-demarcated, mobile, nontender, and firm. If the infection remains untreated, the nodes soften, become fluctuant, and adhere to the skin, which may be erythematous.
  • In Hodgkin disease, nodes are initially soft. They later become firm and rubbery.
• Fixation of lymph nodes to the skin and soft tissue may indicate malignancy.
• Tenderness
• • Lymph nodes of infectious etiology are usually tender.
  • Bubonic plague, caused by Y pestis, may cause extremely tender lymph node enlargement and erythema of overlying skin in the inguinal, femoral, axillary, or cervical area.
  • Hodgkin lymphoma may initially present as painless lymph node enlargement, especially of the cervical and supraclavicular region.
• Overlying skin
• • The overlying skin may be erythematous in infectious etiologies.
  • Draining sinuses may develop in patients with tuberculous adenopathy.
  • Infants with atopic eczema may have generalized lymphadenopathy.
• Systemic signs
• • Group B streptococcal cellulitis and adenitis, which may occur in infants younger than 2 months, are characterized by sudden onset of fever, anorexia, irritability, and submandibular swelling. Usually, a blood culture test demonstrates positive results.
  • Hepatosplenomegaly is common in patients with infectious mononucleosis.
• Conjunctivitis
• • Preauricular adenopathy (Parinaud oculoglandular syndrome) secondary to uniocular granulomatous conjunctivitis may be caused by catscratch disease, chlamydial conjunctivitis, listeriosis, tularemia, or tuberculosis.
  • Adenovirus type 3 causes pharyngeal conjunctival fever. Symptoms associated with adenovirus type 3 include follicular conjunctivitis with enlarged preauricular and/or posterior cervical nodes. Adenovirus type 8 causes epidemic keratoconjunctivitis, which causes preauricular adenopathy.
• PFAPA syndrome: Aphthous stomatitis and pharyngitis are associated with PFAPA syndrome.
• Number: A single node or multiple nodes may be involved.
• Catscratch disease: In catscratch disease, usually only a single node is involved.

Causes

• Infections
• • Acute, one-sided, pyogenic adenitis is most common. The involved node may be firm and tender, with erythema of the overlying skin. Etiologic agents include group A beta-hemolytic streptococci, staphylococcal organisms (especially Staphylococcus aureus),³ and viruses.
  • Tularemia may be accompanied by regional adenopathy, most commonly cervical, with local tenderness, pain, and fever. Generalized lymphadenopathy may also develop.⁴
  • In a child with tuberculosis, generalized lymphadenopathy may indicate hematogenous spread of tubercle bacilli. Localized involvement is most common in the mediastinal, mesenteric, or anterior cervical nodes. Initially, the nodes are discrete, firm, mobile, and tender. If the patient remains untreated, the nodes soften, become fluctuant and matted, and adhere to overlying skin, which may become erythematous. Bilateral involvement is characteristic of this condition. Pulmonary disease is common.
  • Atypical mycobacteria can manifest cervical or submandibular involvement identical to that of tuberculosis, except the involvement is usually unilateral.
  • Group B streptococcal cellulitis and adenitis may occur in infants younger than 2 months.
  • Brucellosis may accompany chronic or intermittent lymphadenopathy.
  • Y enterocolitica may be associated with cervical lymphadenitis.
  • Salmonella infection can correspond to generalized adenopathy.
  • Bubonic plague is caused by Y pestis.
  • In patients with catscratch disease, the site of the scratch determines if axillary, epitrochlear, supraclavicular, femoral, inguinal, or submaxillary lymph nodes are involved. The nodes are nontender, discrete, mobile, and moderately or greatly enlarged. Occasionally, tenderness, redness, warmth, and suppuration may occur. Bartonella henselae is the organism that causes catscratch disease.
  • Patients with infectious mononucleosis typically present with discrete, firm, nontender lymph nodes. Usually, anterior cervical nodes are involved. Generalized lymphadenopathy may occur, and hepatosplenomegaly is common.
  • Cytomegalovirus or toxoplasmosis may cause a mononucleosislike syndrome with generalized adenopathy, fever, atypical lymphocytes, and hepatosplenomegaly.
  • Gianotti-Crosti syndrome accompanies generalized lymphadenopathy, hepatomegaly, splenomegaly, nonicteric hepatitis, and crops of papular lesions that persist for 2-8 weeks.
• Immunologic or connective tissue disorders
• • Juvenile rheumatoid arthritis should be considered in unexplained fever and persistent lymphadenopathy in a child.
  • Serum sickness can correspond with generalized tender lymphadenopathy.
  • Chronic graft versus host disease may occur.
• Primary disease of lymphoid or reticuloendothelial tissue
• • Acute leukemia
  • Lymphosarcoma
  • Reticulum cell sarcoma
  • Hodgkin disease
  • Non-Hodgkin lymphoma
  • Malignant histocytosis or histocytic lymphoma
  • Nonendemic Burkitt tumor
  • Nasopharyngeal rhabdomyosarcoma
  • Neuroblastoma⁵
  • Thyroid carcinoma, chronic lymphocytic thyroiditis
  • Histiocytosis X
  • Kikuchi disease⁶
  • Benign sinus histiocytosis
  • Angioimmunoblastic or immunoblastic lymphadenopathy
  • Chronic pseudolymphomatous lymphadenopathy (chronic benign lymphadenopathy)
• Immunodeficiency syndromes and phagocytic dysfunction
• • Chronic granulomatous disease of childhood
  • Acquired immunodeficiency syndrome
  • Hyperimmunoglobulin E (Job) syndrome
• Metabolic and storage diseases
• • Gaucher disease
  • Niemann-Pick disease
  • Histiocytosis X
  • Cystinosis
• Hematopoietic diseases
• • Sickle cell anemia
  • Thalassemia
  • Congenital hemolytic anemia
  • Autoimmune hemolytic anemia
• Other disorders
• • Kawasaki disease usually presents with cervical adenopathy that is unilateral and with nodes that are firm, nontender, and greater than 1.5 cm in diameter. Overlying skin may be erythematous but not warm.⁷
  • PFAPA syndrome usually occurs in young children (onset almost always before age 5 y) and is remarkable because of its regular periodicity. All findings may not occur in each patient. Children are otherwise healthy between episodes and display normal growth and development. During the acute episodes, elevation of inflammatory markers (eg, WBC count, erythrocyte sedimentation rate) is often present.
  • Drug use can affect lymph nodes. Mesantoin use may cause enlargement of lymph nodes (most commonly in the cervical region), fever, eosinophilia, rash, and hepatosplenomegaly. Hydantoin use also may produce lymphadenopathy as an adverse effect.
  • Almost all patients with sarcoidosis demonstrate either generalized or hilar lymphadenopathy. When enlarged, bilateral cervical nodes are firm, rubbery, and discrete, with little tendency to coalesce. Other symptoms include fatigue, cough, fever, dyspnea, and weight loss. Hyperglobulinemia and eosinophilia are common laboratory findings.
  • Castleman disease or benign giant lymph node hyperplasia may cause lymphadenopathy in the mediastinum, abdomen, neck, or axilla. Some patients experience fever, anemia, weight loss, and hyperglobulinemia.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Lymphoma
Mycobacterial infection
Kikuchi disease
PFAPA syndrome

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Gram stain: Staining can be performed on aspirated tissue. Gram staining is a quick method used to evaluate bacterial etiologies.
• Culture of aspirated tissue or biopsy specimen: Culturing is performed to determine the causative organism and sensitivity to antibiotics.
• Monospot: Monospot (in older children) or Epstein-Barr virus (EBV) serologies are useful to confirm the diagnosis of infectious mononucleosis.
• B henselae serologies: These can be used to confirm the diagnosis of catscratch disease.
• Skin testing: Purified protein derivative testing can be helpful in confirming the diagnosis of tuberculous lymphadenopathy and may be suggestive of atypical mycobacterial infection.
• CBC count: A high WBC count may indicate an infectious etiology.
• Erythrocyte sedimentation rate: A high erythrocyte sedimentation rate is a nonspecific indicator of inflammation.
• Liver function tests: These may indicate hepatic or systemic involvement. An elevation may occur in infectious mononucleosis.

Imaging Studies

• Ultrasonography: Images may be helpful in detecting the extent of the spread of lymphadenopathy.⁸
• Chest radiography: Radiography may be helpful in determining pulmonary involvement or spread of lymphadenopathy to the chest.

Procedures

• Needle aspiration
• Partial or excisional biopsy
• Incision and drainage

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• In patients with lymphadenopathy, treatment depends on the causative agent and may include the following:
• • Antimicrobial therapy
  • Expectant management: Catscratch disease is usually benign and self-limited and generally does not require treatment with antibiotics.
  • Chemotherapy
  • Radiotherapy
• For details on medical therapy, please refer to the eMedicine article that discusses the specific diagnosed condition, including the following:
• • Cytomegalovirus
  • Toxoplasmosis
  • Gianotti-Crosti syndrome
  • Graft versus host disease
  • Non-Hodgkin lymphoma
  • Hodgkin disease
  • Neuroblastoma
  • Hyperimmunoglobulin E (Job) syndrome
  • Gaucher disease
  • Niemann-Pick disease
  • Sickle cell anemia
  • Thalassemia
  • Kawasaki disease
  • Dental abscess
  • Pharyngitis
  • Mononucleosis
  • Tularemia
  • Yersinia enterocolitica infection
  • Salmonella infections
  • Rubella
  • Tuberculosis
  • Sinusitis
  • Histoplasmosis
  • Candidiasis
  • Bronchiectasis

Surgical Care

Depending on presentation, the following procedures may be appropriate:

• Excisional biopsy: Lymphadenitis caused by atypical mycobacteria may have improved cosmetic outcome with surgical excision.
• Aspiration
• Incision and drainage

Consultations

Depending on the etiology, consultations with the following specialists may be appropriate:

• Pediatric infectious disease specialist
• Surgeon
• Hematologist
• Oncologist

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Therapy is determined by diagnosis. Refer to the eMedicine article that discusses the diagnosed condition for information about appropriate medications. (See Causes and Treatment).

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Contact the primary medical physician for follow-up care, coordination of care, and referrals, if required.
• Contact a surgeon for procedures such as excision, incision, and drainage.

Further Outpatient Care

• Contact the primary care provider to ensure lesion resolution and treatment compliance.

Complications

• Cellulitis
• Suppuration
• Systemic involvement
• Internal jugular vein thrombosis
• Septic embolic phenomena
• Carotid artery rupture
• Mediastinal abscess
• Purulent pericarditis

Prognosis

• Prognosis depends on the etiology of the lymphadenopathy and when intervention is started. Infectious processes usually have better outcome if treatment is initiated early.

Patient Education

• Instruct patients and parents in the use and importance of medications and regular follow-up.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Knowledge of the many and sometimes rare causes of lymph node enlargement is important to initiate the appropriate workup.
• Patients with lymph node enlargement are usually concerned about malignancy; address these concerns early on.
• Misdiagnosis of potentially life-threatening etiologies may have medicolegal implications for the physician.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. Friedmann AM. Evaluation and management of lymphadenopathy in children. Pediatr Rev. Feb 2008;29(2):53-60. [Medline].
2. Fraser L, Moore P, Kubba H. Atypical mycobacterial infection of the head and neck in children: a 5-year retrospective review. Otolaryngol Head Neck Surg. Mar 2008;138(3):311-4. [Medline].
3. Guss J, Kazahaya K. Antibiotic-resistant Staphylococcus aureus in community-acquired pediatric neck abscesses. Int J Pediatr Otorhinolaryngol. Jun 2007;71(6):943-8. [Medline].
4. Guffey MB, Dalzell A, Kelly DR, Cassady KA. Ulceroglandular tularemia in a nonendemic area. South Med J. Mar 2007;100(3):304-8. [Medline].
5. Pepper S, Islam HK, Jayabose S, et al. Neuroblastoma masquerading as cervical lymphadenitis. J Pediatr Hematol Oncol. Apr 2007;29(4):260-1. [Medline].
6. Chuang CH, Yan DC, Chiu CH, et al. Clinical and laboratory manifestations of Kikuchi's disease in children and differences between patients with and without prolonged fever. Pediatr Infect Dis J. Jun 2005;24(6):551-4. [Medline].
7. Rigante D, La Torraca I, Rossodivita A, et al. Unilateral cervical mass as a main clue raising the diagnostic suspicion of Kawasaki syndrome. Rheumatol Int. Nov 2007;28(1):73-6. [Medline].
8. Simanovsky N, Hiller N. Importance of sonographic detection of enlarged abdominal lymph nodes in children. J Ultrasound Med. May 2007;26(5):581-4. [Medline].
9. Ahuja A, Ying M, Yuen YH, Metreweli C. Power Doppler sonography of cervical lymphadenopathy. Clin Radiol. Dec 2001;56(12):965-9. [Medline].
10. Chao SS, Loh KS, Tan KK, Chong SM. Tuberculous and nontuberculous cervical lymphadenitis: A clinical review. Otolaryngol Head Neck Surg. Feb 2002;126(2):176-9. [Medline].
11. Elden LM, Grundfast KM, Vezina G. Accuracy and usefulness of radiographic assessment of cervical neck infections in children. J Otolaryngol. Apr 2001;30(2):82-9. [Medline].
12. Eriksson M, Bennet R, Danielsson N. Non-tuberculous mycobacterial lymphadenitis in healthy children: another "lifestyle disease"?. Acta Paediatr. Nov 2001;90(11):1340-2. [Medline].
13. Green M. Lymphadenopathy. In: Pediatric Diagnosis. 5^th ed. WB Saunders Co; 1992:393-7.
14. Hazra R, Robson CD, Perez-Atayde AR, Husson RN. Lymphadenitis due to nontuberculous mycobacteria in children: presentation and response to therapy. Clin Infect Dis. Jan 1999;28(1):123-9. [Medline].
15. Koybasi S, Saydam L, Gungen Y. Histiocytic necrotizing lymphadenitis of the neck. Am J Otolaryngol. Sep-Oct 2003;24(5):344-7. [Medline].
16. Loeffler AM. Treatment options for nontuberculous mycobacterial adenitis in children. Pediatr Infect Dis J. Oct 2004;23(10):957-8. [Medline].
17. Peters TR, Edwards KM. Cervical lymphadenopathy and adenitis. Pediatr Rev. Dec 2000;21(12):399-405. [Medline].
18. Thomas KT, Edwards KM. Periodic fever syndrome. Pediatr Infect Dis J. Jan 1999;18(1):68-9. [Medline].

Article Last Updated: Apr 14, 2008