Infectious Lymphadenopathy


Region(s) drained by that node




Viral upper respiratory tract infections

Pyogenic infections of head/neck


Cat scratcha


Kawasaki disease


Non-tuberculous mycobacteriaa





Posterior neck and scalp


Seborrheic dermatitis

Tinea capitis


Conjunctivae, eyelids

Viral conjunctivitis (including adenovirus)

Parinaud’s oculoglandular syndrome

Cat scratch diseasea

Chlamydia trachomatis


Submaxillary, submental

Oral cavity, lips

Dental caries or abscesses


Herpetic gingivostomatitis


Intrathoracic, abdomen, arms, thyroid


Nontuberculous mycobacteriaa

Generalized lymphadenopathy
Large DNA viruses: CMV, EBV, HSV, VZV


HIV infection (acute or chronica)



Lyme disease







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







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


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



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


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


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


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



Epidemiology/infection control





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


Cat-scratch (Bartonella henselae)

Scratch from cat or bite from infected flea

Localized adenopathy; poorly healing papule; 30 % with fever; hepatosplenic lesions


Optimal therapy unclear. While usually resolves in 4–6 weeks, symptoms may abate more quickly if children receive antibiotics (azithromycin, fluoroquinolones, TMP-SMX)


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


Urine or placental tissue of infected animals

Biphasic illness with initial fever, conjunctival suffusion, myalgias. Immune-mediated phase with adenopathy, aseptic meningitis, purpuric rash



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



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)


Streptomycin or gentamicin × 10 days

Culture is hazardous to laboratory personnel

Alternative: fluoroquinolones, doxycycline



Cause of epidemic keratoconjunctivitis

Fever, conjunctivitis, preauricular adenopathy, pharyngitis, hepatitis, hemorrhagic cystitis


Supportive care unless child is immunosuppressed or has life-threatening disease


Rapid assays


Most common congenital infection in the U.S. (only 10 % symptomatic at birth)

Fever, fatigue, hepatitis, pharyngitis;


Supportive care unless child is immunosuppressed or has life-threatening disease


splenomegaly less common than in EBV



90 % of U.S. adults have been infected with EBV

Pharyngitis, splenomegaly, fatigue, periorbital edema




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


Castleman’s most common in adolescents


Supportive unless develop HHV-8-associated malignancies (e.g., lymphoma, Kaposi sarcoma)


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


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


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


Supportive care. Vitamin A has been shown to decrease measles mortality in developing nations


The only cause of epidemic parotitis

Parotitis, aseptic meningitis, orchitis, arthritis


Supportive care

Serology of limited utility, as IgM response is very transient


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

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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