What is the treatment for lymphadenitis?

Treatment of Lymphadenitis

For lymphadenitis, the treatment of choice depends on the causative organism, with excisional surgery being the recommended primary treatment for nontuberculous mycobacterial (NTM) cervical lymphadenitis in children, while bacterial lymphadenitis typically requires appropriate antibiotic therapy. 1

Treatment Based on Etiology

Nontuberculous Mycobacterial (NTM) Lymphadenitis

Children with NTM Cervical Lymphadenitis

• First-line treatment: Excisional surgery without chemotherapy

  • Success rate approximately 95% 1
  • Complete removal of affected lymph node is crucial
  • Incisional biopsy alone should be avoided as it may lead to persistent disease, sinus tract formation, and chronic drainage 1

• Alternative approaches (when surgery is high-risk or for recurrent disease):

  • Clarithromycin-based multidrug regimen similar to that used for pulmonary disease 1
  • Options include:
    • Clarithromycin (500 mg twice daily) plus rifampicin 2
    • Treatment duration typically 6-7 months 2

Bacterial Lymphadenitis

• Uncomplicated bacterial lymphadenitis:

  • Narrow-spectrum beta-lactam antibiotics (flucloxacillin or first-generation cephalosporins) 3
  • Target common pathogens: Staphylococcus aureus and Streptococcus pyogenes 4
  • Duration typically 10-14 days

• Complicated lymphadenitis (with abscess formation):

  • Surgical drainage plus antibiotics 5
  • Consider broader antibiotic coverage including clindamycin 3
  • Risk factors for abscess requiring drainage: immunocompromised host, male sex, and prior inadequate treatment 5

Special Considerations

Tuberculous Lymphadenitis

• Follow standard tuberculosis treatment protocols
• Typically requires 6-9 months of therapy with INH, RIF, PZA, and EMB 1
• Initial 2 months: INH, RIF, PZA, and EMB
• Followed by 4-7 months of INH and RIF 1

Adult Patients with Extrapulmonary NTM Disease

• For localized disease involving skin, soft tissue, tendons, joints, or bone:
  • Combination of excisional surgery/debridement and chemotherapy 1
  • Drug regimen similar to MAC pulmonary disease (clarithromycin, rifampin, ethambutol)
  • Treatment duration typically 6-12 months 1

HIV-Positive Patients with Lymphadenitis

• Until diagnosis is confirmed by culture, treat as tuberculosis 1
• For confirmed NTM lymphadenitis, treatment should be guided by species identification
• Restoring immunocompetence with antiretroviral therapy is crucial 1

Diagnostic Considerations

• Cervical lymphadenitis in children under 5 years is commonly caused by NTM 2
• Acute bilateral cervical lymphadenitis is usually viral or streptococcal in origin 4
• Acute unilateral cervical lymphadenitis is typically caused by streptococcal or staphylococcal infection (40-80% of cases) 4
• Subacute or chronic lymphadenitis should raise suspicion for cat-scratch disease, mycobacterial infection, or toxoplasmosis 6

Pitfalls and Caveats

1. Avoid incisional biopsy alone for suspected NTM lymphadenitis as it may lead to chronic drainage and sinus tract formation 1

2. Consider tuberculosis when a child with granulomatous disease has a strongly positive PPD tuberculin skin test (≥15 mm); initiate anti-TB therapy while awaiting culture results, especially with TB risk factors 1

3. Do not rely solely on anti-TB drugs (without a macrolide) for NTM lymphadenitis as this approach has frequently led to persistent clinical disease 1

4. Be aware that lymph nodes may enlarge during appropriate therapy for tuberculous lymphadenitis without indicating treatment failure 1

5. Recognize that surgical drainage of bacterial lymphadenitis carries risks including nerve injury 2

By following these evidence-based treatment approaches, most cases of lymphadenitis can be effectively managed with excellent outcomes in terms of morbidity, mortality, and quality of life.