What is the appropriate evaluation and management for a 14-year-old patient with a 2-month history of cervical lymphadenopathy?

Evaluation of Cervical Lymphadenopathy in a 14-Year-Old

A 14-year-old with persistent cervical lymphadenopathy for 2 months requires a thorough evaluation to rule out malignancy, with ultrasound imaging and possible biopsy if suspicious features are present.

Initial Assessment

History

• Duration of lymphadenopathy (≥2 weeks duration is concerning for malignancy) 1
• Associated symptoms:
  • Constitutional symptoms: fever, night sweats, weight loss (concerning for malignancy or systemic disease) 2
  • Localized symptoms: pain, tenderness, recent upper respiratory infection 1
• Recent infections, dental problems, trauma, or insect bites 1
• Travel history and animal exposures 1
• Medication history 2

Physical Examination

• Characteristics of lymph nodes (suspicious features include):
  • Size >1.5 cm 1
  • Firm consistency 1
  • Fixed/immobile nodes 1
  • Ulceration of overlying skin 1
• Location of lymphadenopathy:
  • Unilateral vs bilateral 3
  • Anterior cervical (less concerning) vs supraclavicular/posterior cervical (more concerning for malignancy) 3
  • Presence of other enlarged lymph nodes (generalized lymphadenopathy) 2
• Complete head and neck examination:
  • Oropharyngeal inspection for signs of infection or masses 1
  • Skin examination for rashes, lesions 1

Diagnostic Workup

Laboratory Studies

• Complete blood count with differential 1
• Inflammatory markers (ESR, CRP) 1
• Consider specific serologies based on clinical suspicion:
  • EBV, CMV, toxoplasmosis if subacute presentation 3
  • HIV testing if risk factors present 1

Imaging

• Ultrasound is the preferred initial imaging modality 4:
  • Evaluates size, morphology, vascularity, and presence of necrosis
  • Multiple enlarged nodes with preserved architecture suggest reactive lymphadenopathy
  • Hypoechoic core suggests bacterial infection 1
  • Loss of normal architecture, round shape, and heterogeneous echogenicity suggest malignancy 4
• Consider chest X-ray to evaluate for mediastinal lymphadenopathy or pulmonary disease 5
• CT or MRI may be indicated if:
  • Deep neck involvement is suspected 1
  • Ultrasound findings are concerning 4
  • Lymphadenopathy persists despite appropriate treatment 4

Management Algorithm

1. If infectious etiology is suspected:

   • Consider a single course of broad-spectrum antibiotics if signs of bacterial infection are present 1
   • Re-evaluate within 2 weeks 1
   • If complete resolution occurs, follow up once more in 2-4 weeks to confirm 1
   • If partial or no resolution, proceed to further workup 1

2. If lymphadenopathy persists >2 weeks without signs of infection:

   • Proceed directly to ultrasound imaging 4
   • Based on ultrasound findings:
     • If benign features: close monitoring with follow-up in 4-6 weeks 4
     • If suspicious features: consider biopsy 1

3. Indications for biopsy:

   • Persistence beyond 4-6 weeks without diagnosis 2
   • Size >2 cm without improvement 2
   • Supraclavicular location 2
   • Presence of suspicious features (firm, fixed, non-tender) 1
   • Abnormal imaging findings 4

4. Biopsy options:

   • Fine-needle aspiration: less invasive but may not provide definitive diagnosis 2
   • Core needle biopsy: better tissue architecture while still minimally invasive 2
   • Excisional biopsy: gold standard for definitive diagnosis, especially if lymphoma is suspected 2

Common Diagnoses to Consider

• Infectious causes:

  • Viral (EBV, CMV, adenovirus) - most common cause in children 4
  • Bacterial (Streptococcus, Staphylococcus) 3
  • Mycobacterial infections 3
  • Cat scratch disease (Bartonella henselae) 3

• Malignant causes:

  • Lymphoma (Hodgkin's and non-Hodgkin's) 2
  • Leukemia 2
  • Metastatic disease (rare in this age group) 1

• Other causes:

  • Autoimmune disorders 2
  • Kawasaki disease (if accompanied by fever and other characteristic findings) 1

Important Caveats

• Persistent cervical lymphadenopathy (>2 months) in a 14-year-old should never be dismissed without proper evaluation 1
• Empiric antibiotics should not be given without evidence of infection as they may delay diagnosis of malignancy 1
• Supraclavicular nodes are always abnormal and have higher risk of malignancy 2
• Corticosteroids should be avoided before diagnosis as they may mask symptoms of lymphoma and interfere with pathologic diagnosis 2
• Even if initial evaluation is reassuring, follow-up is essential until complete resolution or definitive diagnosis 1