What is the treatment for lymphadenitis?

Treatment of Lymphadenitis

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

Treatment Based on Etiology

Bacterial Lymphadenitis

• Acute bacterial lymphadenitis (most common cause: Staphylococcus aureus or Streptococcus pyogenes):
  • First-line treatment: Empiric antibiotics effective against S. aureus and S. pyogenes 2
    • Consider local MRSA prevalence when selecting antibiotics
  • For suppurative (abscess-forming) lymphadenitis: Surgical drainage plus antibiotics
  • Duration: Typically 10-14 days of antibiotics

Nontuberculous Mycobacterial (NTM) Lymphadenitis

• Primary treatment: Complete excisional surgery without antibiotics 1
• For recurrent disease: Second surgical procedure
• For high surgical risk cases (e.g., risk of facial nerve damage with preauricular nodes):
  • Clarithromycin-based multidrug regimen similar to that used for pulmonary MAC disease 1
  • Regimen: Clarithromycin (500-1,000 mg daily) or azithromycin (250 mg daily), rifampin (600 mg) or rifabutin (150-300 mg), and ethambutol (15 mg/kg) 1

Granulomatous Lymphadenitis (Mediastinal)

• Mild cases: Usually no treatment needed 1
• Symptomatic cases: Itraconazole (200 mg 3 times daily for 3 days, then once or twice daily for 6-12 weeks) 1
• Severe cases with compression of surrounding structures:
  • Prednisone (0.5-1.0 mg/kg daily, maximum 80 mg daily) in tapering doses over 1-2 weeks 1
  • Add itraconazole if corticosteroids are administered to prevent progressive infection 1

Special Considerations

Diagnostic Approach When Etiology is Unclear

• For persistent lymphadenopathy (>4 weeks) or accompanying systemic symptoms:
  • Laboratory studies: CBC, CRP, ESR, tuberculosis testing 3
  • Imaging: Ultrasound, CT, or MRI depending on location
  • Biopsy options: Fine-needle aspiration, core needle biopsy, or excisional biopsy 3

Important Cautions

• Avoid incisional biopsy alone for suspected NTM lymphadenitis as it may lead to persistent clinical disease, sinus tract formation, and chronic drainage 1
• Avoid anti-TB drugs alone (without a macrolide) for NTM lymphadenitis 1
• Avoid corticosteroids without a definitive diagnosis as they can mask lymphoma or other malignancies 3
• For suspected TB: If a child has granulomatous disease with a strongly positive PPD tuberculin skin test (≥15 mm), initiate anti-TB therapy while awaiting lymph node culture results, especially with TB risk factors 1

For Extrapulmonary, Localized MAC Disease in Adults

• Treatment: Combination of excisional surgery (or surgical debridement) and chemotherapy 1
• Drug regimen: Same as for MAC pulmonary disease
• Duration: 6-12 months of chemotherapy 1

Monitoring and Follow-up

• Monitor for response to treatment with clinical examination
• For patients not responding to empiric antibiotics, re-evaluate for:
  1. Need for surgical intervention
  2. Alternative microbiologic diagnoses 2
  3. Possible malignancy

This treatment approach prioritizes surgical excision for NTM lymphadenitis while using appropriate antibiotics for bacterial causes, with specific modifications based on disease severity, location, and patient factors.