What is the initial workup for a child presenting with a hard and tender lymph node?

Initial Workup for a Child with Hard and Tender Lymph Node

The initial workup for a child with a hard and tender lymph node should include an excisional lymph node biopsy or at least a core biopsy to establish a definitive diagnosis, as fine-needle aspiration is insufficient for appropriate diagnosis. 1

Diagnostic Approach

Clinical Assessment

• Detailed history focusing on:
  • Duration of lymphadenopathy
  • Associated symptoms (fever, weight loss, night sweats)
  • Recent infections or exposures
  • Medications
  • Travel history
• Physical examination with attention to:
  • Size, consistency, mobility, and tenderness of the lymph node
  • Distribution (localized vs. generalized)
  • Presence of other enlarged lymph nodes
  • Examination of areas that drain to the affected node

Initial Laboratory Tests

• Complete blood count (CBC) with differential
• Comprehensive metabolic panel
• Lactate dehydrogenase (LDH)
• Erythrocyte sedimentation rate (ESR)
• Screening tests for relevant infections:
  • EBV and CMV serologies (most common viral causes) 2
  • HIV testing
  • Tuberculosis testing when clinically indicated

Imaging

• Ultrasonography is the first-line imaging modality for evaluating cervical lymphadenopathy in children 3, 4
  • Evaluate for:
    • Size and shape (oval with predominance of long axis is typically benign)
    • Hilum (proper width suggests benign etiology)
    • Vascularization pattern
    • Presence of necrosis or calcification

Biopsy Considerations

• Excisional biopsy is the gold standard for definitive diagnosis 2
• Indications for biopsy:
  • Failure of regression after 4-6 weeks of observation or antibiotic therapy 4
  • Lymph nodes >2 cm in diameter
  • Hard, fixed, or rapidly enlarging nodes
  • Supraclavicular location
  • Abnormal ultrasonographic features
  • Constitutional symptoms (fever, weight loss, night sweats)

Management Algorithm

1. For typical inflammatory lymphadenopathy:

   • Trial of appropriate antibiotics if bacterial infection is suspected
   • Re-evaluation in 2-4 weeks
   • If regression occurs, continue observation

2. For persistent lymphadenopathy (>4-6 weeks):

   • Proceed with excisional biopsy 4
   • Ensure proper handling of specimen for:
     • Histopathology
     • Microbiological cultures
     • Immunophenotyping if lymphoma is suspected

3. For suspicious features (hard, fixed, rapidly growing):

   • Expedite diagnostic workup
   • Consider early biopsy rather than observation

Common Pitfalls to Avoid

1. Relying on fine-needle aspiration: Fine-needle aspirations should be avoided as they are insufficient for appropriate diagnosis 1

2. Delaying biopsy: Persistent lymphadenopathy (>4-6 weeks) without improvement should prompt biopsy to rule out malignancy 4, 5

3. Inadequate specimen handling: Ensure proper preservation of tissue for all potential diagnostic studies (histology, microbiology, immunophenotyping) 6

4. Overlooking systemic disease: Evaluate for signs of systemic illness that may present with lymphadenopathy

5. Incomplete imaging: Ultrasonography should evaluate node shape, hilum, and vascularization pattern to distinguish benign from malignant features 4

While most cases of lymphadenopathy in children are due to benign infectious causes, the possibility of malignancy must always be considered, with non-Hodgkin lymphoma being the most common malignant etiology in children with persistent lymphadenopathy 2.