What should be prescribed for a swollen lymph node?

Management of Swollen Lymph Nodes

The treatment of a swollen lymph node should focus on identifying and addressing the underlying cause rather than prescribing medication for the lymphadenopathy itself, with observation being appropriate for most cases of asymptomatic lymphadenopathy lasting less than 4 weeks.

Diagnostic Approach

When evaluating a patient with lymphadenopathy, consider:

• Location: Differentiate between localized and generalized lymphadenopathy

  • Supraclavicular, popliteal, and iliac nodes are always abnormal
  • Epitrochlear nodes >5mm are abnormal
  • Nodes >1-2 cm are generally considered abnormal

• Duration: Acute (<2 weeks) vs persistent (>4 weeks)

• Concerning features:

  • Hard, fixed, or matted nodes
  • Size >2 cm
  • Rapidly enlarging nodes
  • Associated systemic symptoms (fever, night sweats, weight loss)
  • Age >40 years (higher risk of malignancy)

Management Algorithm

1. For Acute Lymphadenopathy (<4 weeks) with Suspected Infection:

• Consider a course of antibiotics (4-6 weeks) if bacterial infection is suspected 1

  • Particularly appropriate for acute unilateral cervical lymphadenitis
  • Reassess after antibiotic course

• Avoid corticosteroids as they can mask lymphoma or other malignancies 1, 2

2. For Persistent Lymphadenopathy (>4 weeks):

• Diagnostic testing is indicated:

  • Laboratory studies: CBC, CRP, ESR, TB testing as appropriate
  • Imaging: Ultrasound as first-line, CT or MRI for nodes ≥5 cm or with suspicious features 1

• Biopsy options for definitive diagnosis:

  • Fine-needle aspiration (FNA) for initial evaluation in adults
  • Core needle biopsy
  • Excisional biopsy (gold standard for lymphoma diagnosis) 1

3. For Confirmed Nontuberculous Mycobacterial (NTM) Lymphadenitis:

• Complete excisional surgery without chemotherapy (95% success rate) 1

  • Preferred approach, especially in children

• Alternative: Clarithromycin-based multidrug regimen for high surgical risk patients 1

Special Considerations

• Malignancy risk is higher in:

  • Adults >40 years
  • Supraclavicular lymphadenopathy
  • Persistent lymphadenopathy with systemic symptoms
  • Approximately 50% of persistent neck masses in adults are malignant 1

• Referral indications to specialist:

  • Persistent lymphadenopathy >4 weeks
  • Nodes with suspicious features
  • Need for excisional biopsy 1

• For confirmed malignancy: Imaging (preferably MRI) to assess extent is necessary 1

Common Pitfalls to Avoid

1. Prescribing corticosteroids before establishing a diagnosis - this can mask lymphoma 1, 2

2. Delaying biopsy in high-risk patients (>40 years with persistent lymphadenopathy)

3. Focusing only on the lymph node without searching for a primary cause - thorough examination of surrounding areas is essential 1

4. Assuming benign etiology without appropriate follow-up - approximately 50% of persistent neck masses in adults are malignant 1

Remember that most cases of lymphadenopathy are benign and self-limited, but persistent or concerning lymphadenopathy requires thorough evaluation to rule out serious underlying conditions.