Hematology / Oncology

Lymphadenopathy

Background

Lymph nodes are not usually palpable in the newborn period. However, with progressive antigenic exposure, this tissue expands in volume, producing palpable cervical, axillary, and inguinal nodes throughout the childhood years. Progressive lymph node atrophy begins during adolescence in turn. Thus, lymph node size depends on the person’s age as well location and antecedent immunological events.

Lymph node enlargement is considered abnormal during the childhood period as the diameter exceeds 1cm in the cervical and axillary chains and 1.5cm in the inguinal chains. Such enlargement is most commonly caused by the proliferation of normal lymphoid components in response to benign, self-limited disease processes, including viral infections, but may also occur secondary to the accumulation of inflammatory cells in response to infection of the node itself (lymphadenitis), or infiltration with malignant cells (lymphoma).

A careful history and complete physical examination will often aid in making the diagnosis and determining the etiology of the lymphadenopathy.

Pertinent questions that should be asked:

  1. Age of the patient?
  2. Location of the enlarged nodes or mass?
  3. How long has the node been noticeably enlarged?
  4. Has the patient been ill recently?
  5. Are there symptoms of sore throat, dysphagia or odynophagia, drooling?
  6. What is the status of the patient’s teeth?
  7. Are there symptoms or signs of skin lesions or inflammation?
  8. Has the child received all immunizations? Has the child received immunizations recently?
  9. Is the child currently taking any medications?
  10. Has the child had recent exposures to cats, pets, wild animals, and/or raw/undercooked meat?
  11. Has the family traveled recently?
  12. Has there been an exposure to TB?
  13. If this is an adolescent patient in particular, is the patient sexually active? Has the patient used intravenous drugs?

Physical examination findings helpful in making the diagnosis:

  1. Cervical and axillary nodes less than 10mm and inguinal nodes less than 15mm are considered normal during childhood
  2. Mobile, discrete, non-tender nodes – often suggests “benign” presentation
  3. Tenderness, erythema, and warmth of overlying skin – may suggest acutely infected nodes
  4. Fluctuance of the node or mass – may suggest abscess formation
  5. Firm and non-tender, matted or fixed to underlying tissue or overlying skin – may suggest malignancy
  6. Evidence of red throat and tonsilar exudates
  7. Evidence of skin lesion or inflammation in an area which may be drained by lymph nodes
  8. Evidence of lymph node enlargement in other regions consistent with generalized lymphadenopathy
  9. Evidence of hepatic and/or splenic enlargement
  10. Evidence of pallor, petechiae, jaundice, or bruising

Differential diagnosis for generalized lymphadenopathy:

Generalized lymphadenopathy is defined as enlargement of >2 non-contiguous lymph node regions. It is often secondary to systemic disease and associated with systemic findings.

Differential diagnosis of lymphadenopathy by region:

Regional lymphadenopathy is often secondary to infection within the involved node and/or its drainage area. Common viral and bacterial infections are the most common causes of adenopathy, especially in association with common viral URIs and bacterial pharyngitis. Localized lymphadenitis is most frequently attributed to staphylococci and beta-hemolytic streptococci infection. Recall, firm, fixed nodes should raise the question of malignancy irrespective of the presence or absence of systemic symptoms and signs.

  • Common viral infections: adenovirus, CMV, enterovirus, EBV, varicella, HSV
  • Common bacterial infections: staphylococcus, GAS, bartonella, tularemia, brucellosis
  • Common malignant etiologies: Hodgkin’s disease, lymphoma, leukemia, metastases
  • Other non-infectious etiologies: histiocytosis, SLE, JIA, Kawasaki disease

Other masses, which may mimic localized lymphadenopathy:

  • Branchial cleft cysts
  • Lipomas
  • Cystic hygromas
  • Salivary glands
  • Thyroglossal duct cysts (in the midline)

Evaluation and treatment:

Evaluation and treatment is guided by the probable etiology determined by history and physical exam. If the presentation is consistent with a viral infection, no further intervention is necessary. If bacterial infection is suspected, as in the case of an otherwise healthy child with unilateral cervical lymphadenopathy and without other symptoms and signs, oral antibiotic treatment covering for S aureus and GAS is indicated (typically with amoxicillin/clavulanate, erythromycin, or cephalexin). The patient may apply heat to the area as well. The patient should be re-evaluated for improvement within a few days. If the lymph node does not continue enlarge, no further treatment is necessary. If the node continues to enlarge despite empiric treatment, becomes fluctuant, causes airway obstruction, or occurs in association with significant toxicity, further evaluation with ultrasound or ST imaging should be pursued, and consultation for aspiration or I&D may be warranted.

If the enlarged node(s) fails to decrease in size within 10-14 days, or if lymphadenpathy is associated with systemic symptoms and signs such as persistent fevers or weight loss, further evaluation is warranted. The diagnostic work-up may include:

  • CBC with differential and smear
  • CMP, LFTs, ESR
  • UA
  • Serologic tests for potential pathogens (EBV, CMV, HIV, bartonella)
  • PPD
  • CXR
  • Imaging (US, CT)
  • Aspirate or excisional biopsy

Subsequent treatment is dependent upon the results of the diagnostic work-up.

References

  1. Kliegman R, et al. (2007). Lymphadenopathy. In Kliegman: Nelson Textbook of Pediatrics, 18th Ed. Saunders, An Imprint of Elsevier Inc. Retrieved 05/30/2011 from http://www.mdconsult.com/books/.
  2. Leung, Alexander KC, and W. Lane M. Robson. Childhood cervical lymphadenopathy. Journal of Pediatric Health Care 18.1 (2004): 3-7.
  3. Friedmann, Alison M. Evaluation and management of lymphadenopathy in children. Pediatrics in Review 29.2 (2008): 53-60.
  4. Sahai, Shashi. Lymphadenopathy. Pediatrics in Review 34.5 (2013): 216-227.
  5. Peters T, Edwards K.  Cervical Lymphadenopathy and Adenitis. Pediatrics in Review. Dec 2000.
  6. Friedmann A. Evaluation and Management of Lymphadenopathy in Children. Pediatrics in Review. Feb 2008