Index
Cervical lymph node enlargement commonly occurs with viral infections.
These “reactive” nodes are usually small, firm, and non-sensitive, and can persist for weeks or months.
Causes of cervical adenopathy
Acute bacterial adenitis is characterized by nodes larger than 10 mm, which are sensitive and can be fluctuating. The most typical is that they are in the front part of the neck.
There is often associated fever and hot skin. Most are caused by Staphylococcus Aureus or Group A Streptococcus (Strep pyogenes). A site of entry can be found, for example, mouth or scalp. Anaerobic bacteria can be associated with dental disease in older children.
Persistent lymph node enlargement can be due to several other conditions:
Eczema atopico
Persistent significant spread may be associated with atopic eczema. These nodes are often more prominent in the back of the neck and are generally bilateral.
Infections
Infectious mononucleosis can have generalized adenopathy and hepatosplenomegaly:
- Mycobacterium avium complex : adenoaptosis is usually unilateral and most cases occur in the age group under 5 years. Sensitive, slightly fluctuating node that can be tied to underlying structures. Sometimes you see the purplish tone of the skin that covers it. Usually not immunocompromised.
- Mycobacterium tuberculosis: systemic symptoms of fever, malaise, and weight loss.
Symptoms
- Lymph node or persistent nodes for a period greater than 6 weeks.
- Firm and hard lymph node.
- Lymph node greater than 2 cm in size.
- Rapid increase in size.
- Significant involuntary weight loss, night sweats, loss of appetite.
- Unexplained fever
- Lumps in the breast or symptoms suggestive of bronchogenic cancer .
Cervical adenopathy refers to the lymph nodes within the cervical chain. These can also occur in conjunction with lymph nodes in the occipital, submental, or submandibular region.
Most lumpy patients worry about malignancy, but this is not always the case, so never assume this.
While acute leukemia can present with cervical adenopathy, chronic leukemia can present more with nonspecific symptoms and abnormalities on blood test or evidence of splenomegaly.
Diagnosis of cervical adenopathy
- Does the patient look bad?
- Is there any evidence of cachexia?
- Are they feverish?
- Where is the lump? Feel for size, shape, and consistency.
- Is it mobile or is it attached to any surrounding structure or something below it?
Examine the occipital, submandibular, submental, and pre- and postauricular nodes.
ENT examination or examination of the lung fields and sinuses may be relevant, but this will be determined by history. Other possible examinations may include the axillary and inguinal nodes and palpation of hepatosplenomegaly.
Possible investigations
- Routine blood tests may include BCF (crucial if you suspect acute leukemia).
- HIV testing and counseling can be crucial in high-risk patients (a 3-month seroconversion window applies).
- Syphilis (3-month seroconversion window applies) and detection of hepatitis may also be essential.
- Plain chest x-ray if bronchogenic cancer is suspected.
- An ultrasound of the abdomen may also be needed if hepatosplenomegaly is suspected.
- Paul Bunnel test, if positive, indicates infectious mononucleosis that can be treated in primary care.
When to refer
- If the node has persisted for more than six weeks.
- If the node is greater than 2 cm and does not improve.
- If it is growing rapidly.
- Patients with HIV or those diagnosed with syphilis or hepatitis will need more urgent evaluation through the appropriate specialty.
- Unexplained fever in a returning traveler.
- Any significant systemic symptoms.
- Generalized adenopathy.
- Significant abnormalities in blood work or imaging.
- Evidence of hepatomegaly or splenomegaly.
The degree of urgency for the referral will depend largely on the results of the history and the examination. A planned review may be necessary depending on the patient and their level of concern.
Treatment
Medical care
Treatment is determined by the specific underlying etiology of the adenopathy.
Most doctors treat children with cervical adenopathy conservatively. Antibiotics should be given only if a bacterial infection is suspected. This treatment is often given before a biopsy or aspiration is done.
This practice can result in unnecessary prescription of antimicrobials. However, the risks of surgery often outweigh the potential benefits of a short course of antibiotics.
Most enlarged lymph nodes are caused by an infectious process. If aspects of the clinical picture suggest malignancy, such as persistent fever or weight loss, the biopsy should be performed earlier.
Management of superior vena cava syndrome requires emergency care, including chemotherapy and possibly radiation therapy.
Surgical care
Surgical care usually involves a biopsy. If lymphadenitis is present, it may be necessary to aspirate for culture and removal of the affected nodule may be indicated.
Queries
Consultation with a pediatric hematologist, pediatric oncologist, or both is often helpful, especially if the adenopathy appears to be more than reactive. Often the most important decision for these children is whether a further evaluation is necessary; experience in evaluating these children is often very helpful.
The ability to provide careful evaluation of the peripheral blood smear may be particularly important.
Surgical consultation is often helpful for lymph node biopsy, culture needle aspiration, and incision and drainage of obviously infected fluctuating nodes.
Diet
Diet plays a minor role in the pathophysiology of adenopathy.
Internationally, many of the infectious etiologies may be associated with an increased risk of malnutrition.
Exercise
Limitations in activity generally involve associated acute-onset splenomegaly. Any patient with an enlarged spleen may need to restrict himself from contact sports.
In infectious mononucleosis, a ruptured spleen can occur with relatively little trauma and can be fatal.
