What is the approach to a persistent cervical lymph node in a 15-month-old child?

Approach to Persistent Cervical Lymph Node in a 15-Month-Old Child

Complete excisional biopsy is the recommended treatment for persistent cervical lymphadenopathy in a 15-month-old child, particularly when nontuberculous mycobacterial (NTM) infection is suspected, with a success rate of approximately 95%. 1

Initial Assessment

• Determine if lymphadenopathy is localized or generalized, as NTM lymphadenitis is typically unilateral and non-tender 1
• Cervical adenitis is the most common form of NTM disease in children, particularly between 1-5 years of age 1
• Approximately 80% of culture-proven NTM lymphadenitis cases are due to Mycobacterium avium complex (MAC) 1
• Children between 1-5 years old are most susceptible to NTM lymphadenitis due to frequent contact with NTM sources such as soil and water 1

Diagnostic Evaluation

• Perform tuberculin skin test (PPD) to rule out tuberculosis 1
• For larger lymph nodes (≥5 cm) or those in difficult anatomical sites, consider advanced imaging such as MRI or CT 1
• Ultrasound is the initial imaging modality of choice and can provide critical information to aid in diagnosis 2
• Fine-needle aspiration (FNA) may be used for initial evaluation but has limitations 1
• Clinical factors that may predict malignancy include lymph node size greater than 2 cm, multiple levels of adenopathy, and supraclavicular location 2

Management Algorithm

1. For typical NTM lymphadenitis presentation:

   • Complete excisional biopsy without chemotherapy is the recommended first-line treatment 1
   • This approach has a success rate of approximately 95% 1

2. For children with recurrent disease or high surgical risk:

   • Consider a clarithromycin-based multidrug regimen 1

3. If TB is strongly suspected:

   • Consider anti-TB therapy while awaiting lymph node culture results 1
   • Sputum GeneXpert for TB has a true-positive rate of 78.84% while PPD may be positive in only a small percentage of TB patients 3

Important Considerations

• The most common causes of persistent cervical lymphadenopathy in children are reactive hyperplasia (40.32%) and tuberculosis (33.7%), followed by lymphoma (10.3%) and atypical mycobacterial adenitis (6.99%) 3
• Supraclavicular lymph node location is strongly associated with lymphoma and warrants particular attention 3
• While most pediatric cervical lymphadenopathy cases are benign, with infection and reactive lymphoid hyperplasia being far more common than malignancy, persistent lymphadenopathy requires thorough evaluation 2
• Children may present with only fever and a unilateral enlarged cervical lymph node, which can be mistakenly treated as bacterial lymphadenitis with antibiotics 4

Pitfalls to Avoid

• Delaying excisional biopsy in cases of persistent lymphadenopathy (>4 weeks) 3
• Relying solely on PPD for tuberculosis diagnosis, as it may be negative in many TB patients 3
• Mistaking NTM lymphadenitis for bacterial infection and treating with inappropriate antibiotics 4
• Failing to consider malignancy in cases with suspicious features such as supraclavicular location, size >2 cm, or multiple levels of involvement 2