What is the management approach for a toddler with cervical lymphadenopathy?

Management of Cervical Lymphadenopathy in Toddlers

Excisional surgery without chemotherapy is the recommended first-line treatment for toddlers with nontuberculous mycobacterial (NTM) cervical lymphadenitis, with a success rate of approximately 95%. 1

Initial Evaluation

• Key clinical features to assess:

  • Size (nodes ≥1.5 cm are significant)
  • Location (unilateral vs bilateral)
  • Tenderness/pain
  • Duration (acute vs chronic)
  • Associated symptoms (fever, weight loss, night sweats)
  • Overlying skin changes (erythema, fluctuance)

• Differential diagnosis considerations:

  • Viral upper respiratory infections (most common cause)
  • Bacterial infections (Staphylococcus aureus, Group A Streptococcus)
  • Nontuberculous mycobacterial infections (primarily MAC)
  • Kawasaki disease (when accompanied by fever ≥5 days and other clinical criteria)
  • Less commonly: malignancy, Rosai-Dorfman-Destombes disease

Diagnostic Approach

1. For acute, tender, unilateral lymphadenopathy with overlying erythema:

   • Presumptive diagnosis of bacterial lymphadenitis
   • Empiric antibiotic therapy targeting Staphylococcus aureus and Group A Streptococcus
   • First-line: Amoxicillin-clavulanate or clindamycin for 10-14 days 2

2. For subacute/chronic, non-tender, unilateral lymphadenopathy:

   • High suspicion for NTM infection
   • Ultrasound is the preferred initial imaging modality 3
   • Findings suggestive of NTM: matted nodes, hypoechoic center, absence of hilum

3. For bilateral lymphadenopathy with fever:

   • Evaluate for Kawasaki disease criteria (fever ≥5 days plus ≥4 principal features) 1
   • Consider echocardiography if Kawasaki disease is suspected

Management Algorithm

Bacterial Lymphadenitis

• Initial treatment: Empiric antibiotics (amoxicillin-clavulanate or clindamycin)
• If no improvement in 48-72 hours:
  • Ultrasound to assess for abscess formation
  • Needle aspiration or incision and drainage if fluctuant
  • Culture material for targeted antibiotic therapy

Nontuberculous Mycobacterial Lymphadenitis

• First-line treatment: Complete excisional surgery without chemotherapy 1
• For recurrent disease or high surgical risk cases (e.g., facial nerve involvement):
  • Consider clarithromycin-based multidrug regimen 1
• Avoid incisional biopsy alone as it may lead to persistent clinical disease, sinus tract formation, and chronic drainage 1

Kawasaki Disease with Cervical Lymphadenopathy

• Treatment: Intravenous immunoglobulin (IVIG) and aspirin 1
• Follow-up: Echocardiography to monitor for coronary artery abnormalities

Special Considerations

• Tuberculosis risk: If PPD tuberculin skin test is strongly positive (≥15 mm), consider anti-TB therapy while awaiting lymph node culture results, especially with TB risk factors (positive family history, foreign-born child) 1

• Watchful waiting: Appropriate for mild, bilateral, mobile lymphadenopathy with normal overlying skin and no systemic symptoms, typically viral in origin 4

• Indications for biopsy:

  • Persistent or enlarging lymphadenopathy despite appropriate antibiotic therapy
  • Supraclavicular location
  • Firm, fixed, or matted nodes
  • Systemic symptoms (fever, weight loss, night sweats)
  • Abnormal chest radiograph

Follow-up

• For bacterial lymphadenitis: Re-evaluate in 48-72 hours after starting antibiotics
• For NTM lymphadenitis post-excision: Follow-up in 2-4 weeks to ensure proper healing
• For cases managed with watchful waiting: Re-evaluate in 2-4 weeks to ensure resolution

The management of cervical lymphadenopathy in toddlers requires careful consideration of the clinical presentation to guide appropriate diagnostic testing and treatment. While most cases are benign and self-limited, prompt recognition of concerning features is essential to identify cases requiring surgical intervention or further evaluation for systemic diseases.