Site
Region(s) drained by that node
Etiologies
Cervical
Head/neck
Viral upper respiratory tract infections
Pyogenic infections of head/neck
Actinomycosis
Cat scratcha
CMV, EBV
Kawasaki disease
Nocardia
Non-tuberculous mycobacteriaa
Toxoplasmosis
Tuberculosisa
Tularemia
Occipital
Posterior neck and scalp
Rubella
Seborrheic dermatitis
Tinea capitis
Preauricular
Conjunctivae, eyelids
Viral conjunctivitis (including adenovirus)
Parinaud’s oculoglandular syndrome
Cat scratch diseasea
Chlamydia trachomatis
Tularemia
Submaxillary, submental
Oral cavity, lips
Dental caries or abscesses
Herpangina
Herpetic gingivostomatitis
Supraclavicular
Intrathoracic, abdomen, arms, thyroid
Tuberculosisa
Nontuberculous mycobacteriaa
Generalized lymphadenopathy
Large DNA viruses: CMV, EBV, HSV, VZV
Brucella
HIV infection (acute or chronica)
Leishmaniasis
Leptospirosis
Lyme disease
Measles
Mumps
Syphilisa
Toxoplasmosisa
Tuberculosisa
Tularemia
Table 13.2
Infections causing lymphadenopathy more common in returned travelers
Class | Organisms | Region(s) | Epidemiology | Signs/symptoms |
|---|---|---|---|---|
Bacteria | Brucellosis (Brucella species) | Worldwide, but more common in Central and South America, Russia, Middle East | Contact with tissues of infected farm animals or unpasteurized dairy products | Fever, chills, weight loss, hepatosplenomegaly, generalized adenopathy |
Leptospirosis | Worldwide, but more common in tropical climates (and after flooding) | Contact with contaminated water or urine of rodents, opossums, raccoons, or farm animals | Generalized adenopathy, fever, myalgias, conjunctival suffusion, retro-orbital pain, jaundice | |
Melioidosis (Burkholderia pseudomallei) | Northern South America, Indian sub-continent, southeast Asia, northern Australia | More common during the monsoonal wet season | Suppurative parotitis, generalized adenopathy, septic arthritis, pericarditis, necrotizing fasciitis, hepatosplenic abscesses, pneumonia | |
Plague (Yersinia pestis) | The Americas (rural regions), Africa, Asia; in the United States, is endemic in western states | Bite from rodent fleas; pneumonic form can be transmitted person-to-person | Regional adenopathy (buboes) most common in inguinal region, but can be seen in cervical or axillary regions, fever, purpura | |
Tularemia (Francisella tularensis) | Most U.S. cases occur in the summer. | Rabbits, rodents, beavers, ticks, handling of dead animals | Parinaud’s, fever, ulceroglandular syndrome | |
Viruses | HIV | Highest rates in sub-Saharan Africa | Sexual, blood products, mother-to-child transmission, injecting drug use | See text and Table 13.3 |
Measles (rubeola) | Most cases imported from Asia and Africa | Airborne transmission; incredibly infectious | Fever, conjunctivitis, blanchable erythematous rash starting on head and progressing to feet | |
Mumps | Most cases imported from Asia, Eastern Europe | Droplet precautions until 5 days after onset of parotitis | Parotitis, aseptic meningitis, orchitis, arthritis | |
Parasitic or protozoal | Filariasis (Wucheria bancrofti, Brugia species) | Caribbean, Africa, Asia, Pacific Islands | Transmitted by bite of infected mosquitoes | Localized adenopathy associated with adult worms; lymphedema and hydroceles rare in children |
Leishmaniasis | Africa, Indian sub-continent | Transmitted by the phlebotomine sand fly | Cutaneous from with papule progressing to a destructive erosive lesion, most common on face; regional adenopathy. Visceral form (kala-azar) with fever, organomegaly, generalized adenopathy | |
Malaria (Plasmodium species) | Worldwide, except North America, Western Europe, Scandinavia, Australia/New Zealand | Bite of infected mosquito, which often feed at night. Most common in children returning to parents’ native countries who do not obtain antimalarial prophylaxis | Fever, chills, malaise, hepatosplenomegaly, generalized adenopathy; can see CNS, renal involvement or respiratory failure | |
Fungal | Blastomycosis (B. dermatitidis) | Africa, India, Central/South America (as well as southern and central United States) | Inhalation of organisms from soil; no person-to-person transmission | Cutaneous lesions can be polymorphic: ulcers, pustules, verrucous, nodular; disseminated disease also can occur |
Localized Adenopathy
Knowledge of lymphatic drainage patterns can help the clinician determine possible causes of adenopathy. The most common causes of anterior cervical adenopathy will be viral respiratory infections, as these nodes drain the upper airway. Posterior cervical or occipital adenopathy can be seen with scalp infections, including kerions associated with tinea capitis, as these nodes drain the posterior neck and scalp. Preauricular nodes are more commonly associated with conjunctivitis (classically, adenovirus) or other superficial ocular infections. Parinaud’s oculoglandular syndrome is the combination of unilateral conjunctivitis with an ipsilateral preauricular node. Parinaud’s has been associated with tularemia [1], cat scratch disease [2], Epstein-Barr virus (EBV) [3], and Yersinia enterocolitica [4].
Signs of inflammation also can help differentiate among the causes of localized infectious lymphadenopathy. Nontender adenopathy should lead the clinician away from most pyogenic causes, and should increase the index of suspicion for viral upper respiratory infections (URIs) or mycobacterial disease, depending upon the duration of illness. More indolent infections (actinomycosis, nocardiosis) may present without pyrexia. The epidemiology, clinical manifestations, diagnosis, and treatment of the most common causes of pediatric lymphadenopathy are summarized in Table 13.3.
Table 13.3
Epidemiology , clinical manifestations, diagnosis, and treatment of common causes of lymphadenopathy in children
Class | Organism(s) | Epidemiology/infection control | Symptoms | Diagnosis | Treatment | |
|---|---|---|---|---|---|---|
Bacteria | Acute pyogenic (Staphylococcus aureus, Streptococcus pyogenes) | Can be part of endogenous flora | Pharyngitis, abscess, cellulitis (need to evaluate for deep neck infection) | Culture Rapid assays | S. pyogenes: penicillin or amoxicillin | |
for S. pyogenes | S. aureus: TMP-SMX, clindamycin, or cephalexin depending on MRSA rates in the area | |||||
Actinomycosis (A. israelii) | Endogenous human flora causing disease after breakdown in mucocutaneous barriers (including after human bites) or in HIV-infected or CGD patients | Cervicofacial most common: hard nodular lesions on mandible, draining sinus tracts, submandibular adenopathy | Anaerobic culture of normally sterile sites | Penicillin or ampicillin IV× 4–6 weeks followed by months of oral suppressive therapy | ||
Yellow ‘sulfur’ granules visualized on microscopy | ||||||
Brucellosis (B. melitensis and other species) | Zoonotic infection; associated with handling aborted non-human animal fetuses, consumption of unpasteurized milk or undercooked food | Fever, night sweats, malaise, generalized adenopathy, hepatosplenomegaly, arthritis | Culture (need to be held for weeks) | Combination therapy to prevent relapse: rifampin plus either doxycycline or TMP-SMX. For serious infections, gentamicin as part of initial regimen is indicated | ||
Serology | ||||||
Cat-scratch (Bartonella henselae) | Scratch from cat or bite from infected flea | Localized adenopathy; poorly healing papule; 30 % with fever; hepatosplenic lesions | Serology | Optimal therapy unclear. While usually resolves in 4–6 weeks, symptoms may abate more quickly if children receive antibiotics (azithromycin, fluoroquinolones, TMP-SMX) | ||
Histopathology | ||||||
Chlamydia trachomatis | Trachoma exceedingly rare in the US, but a common cause of childhood visual loss in developing nations | Isolated conjunctivitis (develops several days-weeks after birth), not associated with scarring; should be evaluated for chlamydial pneumonia | Nucleic acid amplification tests | Conjunctivitis/pneumonia: oral erythromycin × 14 days | ||
Trachoma: corneal neovascularization | Culture for documentation of suspected sexual abuse | Trachoma: azithromycin 20 mg/kg as single dose recommended by WHO | ||||
Leptospirosis | Urine or placental tissue of infected animals | Biphasic illness with initial fever, conjunctival suffusion, myalgias. Immune-mediated phase with adenopathy, aseptic meningitis, purpuric rash | Serology | Penicillin | ||
Can see Jarisch-Herxheimer reaction after starting penicillin | ||||||
Lyme disease (B. burgdorferi) | Bit of deer ticks (Ixodes) | Early localized: erythema migrans with fever, malaise, painless adenopathy. Other: carditis, arthritis, meningo-encephalitis | Early in illness, clinical diagnosis, as serologies take up to a month to become positive | Early localized: amoxicillin or doxycycline | ||
Early disseminated, late disease: amoxicillin or doxycycline; ceftriaxone or IV penicillin for carditis, meningitis, encephalitis, or persistent/recurring arthritis | ||||||
Nocardiosis (Nocardia nova, brasiliensis, farcinica) | Direct inoculation into skin from vegetative material | Tender shallow ulcers, spread in lymphatic pattern; disseminated disease in immunocompromised children | Culture (indolent organism; need to hold cultures for weeks) | TMP-SMX× 6–12 weeks | ||
Abscess drainage decreases frequency of satellite lesions | ||||||
Weakly acid-fast | Add amikacin or ceftriaxone for deeper infections in immunocompromised hosts | |||||
Non-tuberculous mycobacteria | Most common in preschool-aged children | Nontender chronic lymphadenopathy; overlying violaceous discoloration of skin; formation of sinus tracts | Culture (yield will be low if swabs are sent; instead, caseous material should be drawn up in a syringe and sent directly to the laboratory; characteristic exam and history may favor surgical treatment prior to biopsy) | Combination therapy with azithromycin and either rifampin or ethambutol for the most common isolate, Mycobacterium avium complex (MAC) | ||
Complete excision is superior to medical therapy for otherwise healthy children with isolated adenopathy | ||||||
Tuberculosis (scrofula) | Airborne transmission; N95 mask and negative-pressure room should be utilized | Nontender cervical or supraclavicular nodes; fever. Skin discoloration rare | Culture (often negative, in which case use triad of positive TST, history of contact with an adult with contagious TB, and compatible clinical or radiographic findings) | Isoniazid, rifampin, ethambutol, and pyrazinamide unless drug resistance is suspected or confirmed | ||
PCR | ||||||
Tularemia | Contact with rodents, lagomorphs (rabbits, hares), ticks, beavers, deer flies; aerosolization during yard work | Fever, chills, headache, Parinaud’s oculoglandular syndrome; ulceroglandular syndrome (skin ulcers with tender adenopathy) | Serology | Streptomycin or gentamicin × 10 days | ||
Culture is hazardous to laboratory personnel | Alternative: fluoroquinolones, doxycycline | |||||
Viral | Adenovirus | Cause of epidemic keratoconjunctivitis | Fever, conjunctivitis, preauricular adenopathy, pharyngitis, hepatitis, hemorrhagic cystitis | Culture | Supportive care unless child is immunosuppressed or has life-threatening disease | |
PCR | ||||||
Rapid assays | ||||||
CMV | Most common congenital infection in the U.S. (only 10 % symptomatic at birth) | Fever, fatigue, hepatitis, pharyngitis; | Titers | Supportive care unless child is immunosuppressed or has life-threatening disease | ||
PCR | ||||||
splenomegaly less common than in EBV | Culture | |||||
EBV | 90 % of U.S. adults have been infected with EBV | Pharyngitis, splenomegaly, fatigue, periorbital edema | Titers | Supportive | ||
PCR | ||||||
HHV-8 (Castleman’s disease; Kaposi sarcoma) | Seroprevalence highest in the Mediterranean, Africa, the Middle East, and the Amazon basin | Fever, disseminated adenopathy, masses in mediastinum, head, and neck | PCR | |||
Castleman’s most common in adolescents | Serology | Supportive unless develop HHV-8-associated malignancies (e.g., lymphoma, Kaposi sarcoma) | ||||
HIV | Vertically-acquired infection now rare in U.S. Unusual mode of transmission: premastication of food for infants | Acute HIV infection: fever, malaise, pharyngitis, generalized adenopathy | PCR | Antiretroviral therapy | ||
Serology (may be negative in acute HIV infection) | ||||||
Should be part of screening for adopted and immigrant children | Chronic HIV infection: failure to thrive, hepatosplenomegaly, dermatitis, opportunistic infections | Viral load | Prophylaxis against opportunistic infections | |||
Measles | Airborne transmission; one of the most contagious infectious agents; N95 mask and negative-pressure room should be utilized | Cephalocaudad erythematous maculopapular rash that becomes confluent; conjunctivitis; Koplik spots rare, transient | Serology | Supportive care. Vitamin A has been shown to decrease measles mortality in developing nations | ||
Mumps | The only cause of epidemic parotitis | Parotitis, aseptic meningitis, orchitis, arthritis | PCR | Supportive care | ||
Serology of limited utility, as IgM response is very transient | ||||||
Fungal | Tinea capitis (Trichophyton, Microsporum species) | Fungi can remain viable on fomites for days-weeks | Focal alopecia, brittle hair, kerion formation | Potassium hydroxide wet mounts show arthroconidia within hair shaft | Griseofulvin | |
Blastomycosis (B. dermatitidis) | Endemic in soil in south/central United States and other regions [Table 13.2] | Multiple cutaneous findings [see Table 13.2] with nontender adenopathy | Culture on Sabouraud media | Amphotericin (use of oral agents has not been well-studied in children) | ||
Visualization of thick-walled, broad-based budding yeast in tissue | ||||||
Coccidioidomycosis (C. immitis) | Endemic in soil in southwestern United States | Pneumonia (mimics TB); fever, malaise, erythema nodosum, skin/soft tissue infections in areas of penetrating trauma with regional adenopathy
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