Cervical Lymphadenitis

Gordon H. Sun and Allen M. Seiden

History

A 2-year-old child was admitted after a left-sided neck mass noticed 2 weeks earlier failed to resolve with oral antibiotic therapy. He has had only intermittent fevers with temperatures no greater than 102°F. The neck mass had been mildly tender and red at times and currently was mildly painful and inflamed. He was otherwise asymptomatic, with no report of difficulty breathing, decreased appetite, or neck stiffness. The parents had not noticed any pits or holes within the mass, and no drainage from the mass was observed.

The patient had no significant medical history. He was born full-term, and no head and neck lesions were seen in this child at birth or immediately thereafter. There was no recent history of otitis media, tonsillitis, or pharyngitis. He had not suffered any recent insect bites or trauma to the head or neck. The family did not have any pet cats or dogs at home. The patient had not been on any trips abroad recently. The child was up to date with his immunizations. He was taking amoxicillin at the time of admission, and he had no known allergies.

On physical examination, the child had a slightly elevated temperature of 100.2° F, with otherwise stable vital signs and oxygen saturation of 99 to 100%. He appeared nontoxic and was playful during the examination. The child was not stridulous and was not coughing or drooling. He had a minimal amount of clear rhinorrhea bilaterally. His oral examination demonstrated moderately erythematous pharyngeal mucosa and 2+ tonsils without erythema or exudate. The tongue and uvula were not edematous and were both midline, and there was no posterior pharyngeal swelling. No trismus was noted. There was no facial swelling or rashes. Over his left anterolateral neck there was a roughly 3 × 1 cm area of edema and induration, without significant erythema or fluctuance. The mass was non-tender to palpation. No pits or sinuses were appreciated within the mass. No thyromegaly was noted. The patient was able to move his neck in all directions without apparent difficulty during the examination.

The patient’s neck mass shrank substantially after 48 hours of intravenous (IV) antibiotics were administered. He was subsequently discharged home with an additional course of oral antibiotic therapy.

Differential Diagnosis—Key Points

2. The patient’s age is important in narrowing the differential diagnosis of a neck mass. In adults a newly diagnosed neck mass is generally considered a sign of malignancy (metastasis) until proven otherwise. However, cervical lymphadenitis or cervical lymphadenopathy of infectious or inflammatory origin is the most common underlying cause of a pediatric neck mass, most commonly affecting children from 1 to 5 years of age. This disease process may affect other glands in the head and neck region, as in parotitis or thyroiditis or even involve superinfection of congenital neck lesions such as branchial cleft anomalies or thyroglossal duct cysts.

3. Viruses are the most frequent cause of infectious cervical lymphadenitis in both adults and children. Acute bilateral lymphadenitis is often due to viral infection, such as from Epstein-Barr virus (EBV) or human immunodeficiency virus (HIV), although Streptococcus pyogenes and Mycoplasma pneumoniae have also been known to cause infection in this manner. Group B streptococci are often seen in newborns. The most common infectious agents in acute unilateral lymphadenitis are Staphylococcus aureus and S. pyogenes. Anaerobes may be found in patients with significant dental or periodontal disease. Recent studies have suggested an increasing incidence of drug-resistant staphylococci (MRSA) causing cervical lymphadenitis in all age groups. Fungal infections of the neck from Candida, Histoplasma, or Aspergillus are nearly always seen only in immunocompromised patients.

4. Chronic cervical lymphadenitis is frequently seen in mycobacterial infections, toxoplasmosis, and cat-scratch disease. Mycobacterium tuberculosis