How is lymphadenopathy managed in children?

Management of Lymphadenopathy in Children

Complete surgical excision is the recommended treatment for nontuberculous mycobacterial (NTM) lymphadenitis in children, which accounts for approximately 80% of culture-proven cases of cervical lymphadenopathy in this population. 1

Initial Assessment

• Lymphadenopathy persisting for ≥2 weeks requires thorough evaluation as it may indicate serious underlying conditions including malignancy 2
• Key history elements include:
  • Duration of lymphadenopathy 2
  • Associated symptoms (fever, weight loss, night sweats) 2
  • Recent infections, dental problems, trauma, or insect bites 2
  • Travel history and animal exposures 2
• Physical examination should focus on:
  • Size (>1.5 cm is concerning), consistency, mobility, and presence of overlying skin changes 2
  • Complete head and neck examination including oropharyngeal inspection 2
  • Skin examination for rashes or lesions 2

Diagnostic Approach

• Laboratory studies:
  • Complete blood count with differential 2
  • Inflammatory markers (ESR, CRP) 2
  • HIV testing if risk factors present 2
• Imaging:
  • Ultrasound is the preferred initial imaging modality to assess size, morphology, vascularity, and presence of necrosis 2
  • CT or MRI may be indicated for suspected deep neck involvement 2
  • Contrast-enhanced CT of NTM lymphadenitis typically shows asymmetric adenopathy with ring-enhancing masses 1

Etiologies and Management

Infectious Causes

1. Nontuberculous Mycobacterial (NTM) Lymphadenitis

   • Most common form of NTM disease in children, typically affecting children 1-5 years old 1
   • Approximately 80% of culture-proven cases are due to Mycobacterium avium complex (MAC) 1
   • Clinical presentation:
     • Insidious onset, rarely associated with systemic symptoms 1
     • Typically unilateral (95%) and non-tender nodes 1
     • Nodes may enlarge rapidly and even rupture, forming sinus tracts 1
   • Management:
     • Complete surgical excision is the treatment of choice 1
     • Fine needle aspiration or incision and drainage without complete excision may lead to fistula formation and chronic drainage 1
     • Caution: Excisional biopsy of preauricular lymph nodes carries significant risk of facial nerve injury 1

2. Tuberculous Lymphadenitis

   • Important differential diagnosis for NTM lymphadenitis 1
   • In the US, only about 10% of culture-proven mycobacterial cervical lymphadenitis in children is due to M. tuberculosis 1
   • All patients with suspected mycobacterial lymphadenitis should have a tuberculin skin test 1
   • Management requires antimycobacterial drug therapy and public health tracking 1

3. Acute Bacterial Lymphadenitis

   • Antibiotics may be used to treat acute unilateral cervical lymphadenitis, especially in children with systemic symptoms 3
   • Re-evaluation within 2 weeks is recommended if antibiotics are prescribed 2

Non-Infectious Causes

1. Autoimmune Lymphoproliferative Syndrome (ALPS)

   • Characterized by chronic nonmalignant lymphadenopathy and splenomegaly 1
   • Associated with defects in lymphocyte apoptosis 1
   • Diagnosis based on clinical and laboratory criteria 1

2. Malignancy

   • Risk factors include supraclavicular location of nodes and presence of systemic symptoms 3
   • Lymphoma is a common malignant cause of persistent lymphadenopathy 2
   • Indications for biopsy include persistence beyond 4-6 weeks without diagnosis, size >2 cm without improvement, and presence of suspicious features 2

Management Algorithm

1. Initial Presentation:

   • For suspected infectious etiology with acute symptoms: Consider a single course of broad-spectrum antibiotics with re-evaluation within 2 weeks 2
   • For NTM lymphadenitis: Complete surgical excision is recommended 1

2. Persistent Lymphadenopathy (>2 weeks):

   • Obtain ultrasound imaging 2
   • Consider biopsy if suspicious features are present 2

3. Indications for Biopsy:

   • Persistence beyond 4-6 weeks without diagnosis 2
   • Size >2 cm without improvement 2
   • Presence of suspicious features (firm consistency, fixed/immobile nodes, ulceration of overlying skin) 2
   • For suspected NTM, excisional biopsy is preferred over fine needle aspiration 1

Important Caveats

• Persistent cervical lymphadenopathy (>2 months) should never be dismissed without proper evaluation 2
• Empiric antibiotics should not be given without evidence of infection as they may delay diagnosis of malignancy 2
• Follow-up is essential until complete resolution or definitive diagnosis 2
• Even with excised nodes showing compatible histopathology for NTM, only 50-82% will yield positive cultures 1
• The definitive diagnosis of NTM lymphadenitis is made by recovery of the causative organism from lymph node cultures 1