Infectious Lymphadenopathy


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


aMore chronic infections

CMV cytomegalovirus; EBV Epstein-Barr virus; HIV human immunodeficiency virus, HSV herpes simplex virus, VZV varicella zoster virus




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


CNS central nervous system, HIV human immunodeficiency virus, U.S. United States




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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Nov 5, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Infectious Lymphadenopathy
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