From the Guidelines
Patients with axillary lymphadenitis in the Emergency Room should be referred to a general surgeon or infectious disease specialist, depending on the suspected cause, with consideration of ultrasound imaging to evaluate for abscess formation or to characterize concerning lymph nodes, as recommended by recent guidelines 1. The initial management of axillary lymphadenitis includes obtaining a thorough history and physical examination to determine the likely etiology, which may be infectious (bacterial, viral, or fungal), malignant, or inflammatory.
- Empiric antibiotic therapy should be started if bacterial infection is suspected, typically with coverage for Staphylococcus aureus and Streptococcus species using medications such as clindamycin 300-450mg orally four times daily for 7-10 days or trimethoprim-sulfamethoxazole DS twice daily for the same duration.
- Patients with systemic symptoms (fever, malaise), significant comorbidities, or signs of abscess formation may require admission for IV antibiotics and possible surgical drainage.
- The urgency of follow-up depends on clinical presentation, with severe cases requiring same-day surgical consultation and milder cases appropriate for outpatient follow-up within 2-3 days, as supported by studies such as 1 and 1. This approach allows for proper evaluation of the underlying cause while ensuring appropriate treatment is initiated promptly, ultimately reducing morbidity, mortality, and improving quality of life for patients with axillary lymphadenitis.
- It is essential to consider the patient's overall clinical presentation and medical history when determining the best course of action, as highlighted in guidelines such as 1 and 1.
From the Research
Appropriate Referral for Axillary Lymphadenitis in the ER
When a patient presents with axillary lymphadenitis in the Emergency Room (ER), it is crucial to consider the diverse etiology and variable clinical manifestations of the condition 2. The appropriate referral for such a patient would depend on the severity of the symptoms, the suspected underlying cause, and the need for further diagnostic workup or specialized care.
Considerations for Referral
- Infectious Disease Specialist: If the axillary lymphadenitis is suspected to be caused by an infectious agent, such as bacteria (e.g., Staphylococcus aureus, Streptococcus pyogenes) or other pathogens (e.g., Bartonella henselae, Francisella tularensis), referral to an infectious disease specialist may be necessary for guidance on appropriate antibiotic therapy and management 3, 4.
- Surgical Consultation: In cases where suppurative lymphadenitis is suspected or diagnosed, surgical consultation may be required for potential drainage of abscesses or other surgical interventions 4.
- Pediatrician or General Practitioner: For patients with mild symptoms and no clear indication of a serious underlying condition, referral to a pediatrician (for children) or general practitioner for follow-up and monitoring may be appropriate 5.
Diagnostic Workup
- Laboratory Tests: Referral for laboratory tests, including blood cultures, complete blood count (CBC), and molecular assays (e.g., PCR) to identify the causative agent, may be necessary 3.
- Imaging Studies: Imaging studies, such as ultrasound or computed tomography (CT) scans, may be ordered to evaluate the extent of lymphadenitis and to rule out other conditions 2.
Specialized Care
- Dermatology: If the axillary lymphadenitis is associated with a skin condition or breach, referral to a dermatologist may be necessary for evaluation and management of the underlying skin condition 2.
- Other Specialties: Depending on the suspected underlying cause, referral to other specialties, such as rheumatology (for autoimmune conditions) or oncology (for suspected malignancy), may be necessary.