What is the appropriate management for a 2-year-old presenting with a mass in the left cervical chain, sore throat, cough, anemia, neutropenia, monocytosis, elevated CRP, and abnormal CMP results including hyponatremia and hypoalbuminemia?

Management of a 2-Year-Old with Cervical Mass and Systemic Inflammatory Findings

Immediate Priority: Rule Out Life-Threatening Conditions

This child requires urgent evaluation for Multisystem Inflammatory Syndrome in Children (MIS-C), Kawasaki disease, malignancy (particularly lymphoma), and severe bacterial infection given the constellation of cervical mass, systemic inflammation (elevated CRP, monocytosis), and metabolic derangements (hyponatremia, hypoalbuminemia). 1

Critical First Steps

Obtain SARS-CoV-2 testing immediately (PCR and serology) as this child meets tier 1 screening criteria for MIS-C with fever, elevated CRP, and multiple concerning laboratory features including hyponatremia and hypoalbuminemia. 1

• Perform urgent echocardiogram and ECG to evaluate for coronary artery abnormalities and cardiac dysfunction, as MIS-C can present with cervical lymphadenopathy and systemic inflammation. 1
• Check troponin and BNP as cardiac involvement significantly impacts management and prognosis. 1
• Assess for Kawasaki disease criteria: This child has fever and cervical lymphadenopathy (≥1.5 cm); evaluate for conjunctival injection, oral changes, rash, and extremity changes, as incomplete Kawasaki disease can present with fewer than 4 classic features. 1

Diagnostic Workup for the Cervical Mass

Fine needle aspiration (FNA) of the cervical mass is the most appropriate initial diagnostic step for bilateral or unilateral cervical lymphadenopathy in children, as it is minimally invasive and provides rapid tissue diagnosis. 2

• Ultrasound-guided FNA with on-site cytopathology evaluation increases specimen adequacy and reduces the need for repeat procedures. 2
• If lymphoma is strongly suspected based on clinical presentation (persistent fever, night sweats, weight loss, hepatosplenomegaly), consider core needle biopsy as it has higher sensitivity than FNA for lymphoma diagnosis. 2
• Send FNA specimens for: cytology with differential cell count, Gram stain, bacterial culture (aerobic and anaerobic), acid-fast bacilli stain and culture, and consider PCR for specific pathogens. 1

Laboratory Evaluation Beyond Initial Screening

The combination of neutropenia, monocytosis, anemia, hypoalbuminemia, and hyponatremia is concerning for:

• Severe bacterial infection with bone marrow suppression
• Malignancy (lymphoma or leukemia)
• Systemic inflammatory conditions (MIS-C, Kawasaki disease)

Additional essential tests:

• Peripheral blood smear to evaluate for atypical cells or blasts (malignancy concern). 3
• Ferritin, LDH, and uric acid to assess for tumor lysis syndrome or hemophagocytic lymphohistiocytosis. 3
• Blood cultures before initiating antibiotics, as bacteremia occurs in 18% of pediatric empyema cases and can guide therapy. 1
• ESR in addition to CRP, as both are typically markedly elevated in Kawasaki disease and MIS-C. 1

Imaging Strategy

Avoid CT with IV contrast as the initial imaging study in children when malignancy is suspected, as it provides radiation exposure without definitive tissue diagnosis. 2

• Chest radiograph (PA and lateral) is appropriate initial imaging for respiratory symptoms and can identify mediastinal masses or pulmonary infiltrates. 1
• If mediastinal mass or extensive lymphadenopathy is suspected, ultrasound of the neck and chest can be performed without radiation exposure. 2
• Reserve chest CT for specific indications: non-responding pneumonia with concern for necrotizing pneumonia or abscess, or when surgical planning requires detailed anatomy. 1, 4

Empiric Antibiotic Therapy

Initiate broad-spectrum antibiotics immediately given the severity of presentation with systemic inflammation and neutropenia:

• Ceftriaxone 50-75 mg/kg/day IV (maximum 2 grams/day) for serious infections in children, covering common respiratory pathogens including Streptococcus pneumoniae and Staphylococcus aureus. 5
• Consider adding vancomycin or clindamycin if MRSA or severe necrotizing infection is suspected based on local resistance patterns. 4
• Administer ceftriaxone over 60 minutes in this 2-year-old to reduce risk of adverse effects, and avoid calcium-containing solutions within the same IV line. 5

Monitoring for Complications

Watch for clinical deterioration requiring ICU transfer:

• Worsening respiratory distress, stridor, or inability to maintain oxygenation >90% on room air. 1, 4
• Development of shock (tachycardia, hypotension, altered mental status). 4
• Neurological changes (lethargy, confusion, seizures) which can occur with severe infections or as adverse effects of ceftriaxone in patients with renal impairment. 5

Monitor for specific complications:

• Hemolytic anemia: Check for worsening anemia, as immune-mediated hemolytic anemia can occur with cephalosporins and requires immediate discontinuation. 5
• Hyponatremia progression: Severe hyponatremia correlates with disease severity in pneumonia and requires careful fluid management. 4
• Cardiac dysfunction: Serial troponin, BNP, and ECGs if MIS-C or Kawasaki disease is being considered. 1

Critical Pitfalls to Avoid

• Do not delay FNA or biopsy if malignancy is suspected; waiting for clinical response to antibiotics can delay life-saving chemotherapy. 2
• Do not attribute lymphocytosis in pleural fluid or FNA solely to infection; tuberculosis and malignancy must be excluded with appropriate stains, cultures, and cytology. 1
• Do not assume isolated chronic cough is asthma in children; chronic productive cough is always pathologic and requires investigation for structural lung disease, aspiration, or immunodeficiency. 1, 6
• Do not use over-the-counter cough medications as they are ineffective for symptomatic relief in children. 6

Consultation Requirements

Immediate consultations needed:

• Pediatric infectious disease for guidance on antibiotic selection and evaluation for unusual pathogens. 1
• Pediatric hematology-oncology if FNA suggests malignancy or if peripheral smear shows atypical cells. 2
• Pediatric cardiology if echocardiogram shows abnormalities or if Kawasaki disease/MIS-C is diagnosed. 1
• Pediatric surgery or interventional radiology if drainage of abscess or pleural effusion becomes necessary. 1, 4

Reassessment Timeline

Clinical response should be evident within 48-72 hours of appropriate antibiotic therapy, including:

• Defervescence for at least 12-24 hours. 4
• Improved respiratory effort and oxygen saturation. 4
• Improved activity level and appetite. 4

If no improvement by 48-72 hours, consider:

• Resistant organisms requiring antibiotic modification. 1
• Alternative diagnoses (malignancy, autoimmune disease, MIS-C). 1, 3
• Complications such as abscess formation requiring drainage. 1, 4