Treatment for Axillary Lymphadenitis
The treatment for axillary lymphadenitis depends entirely on the underlying etiology, which must be established through axillary ultrasound followed by image-guided biopsy for definitive diagnosis before initiating any treatment. 1
Initial Diagnostic Workup
Axillary ultrasound is the mandatory first step to characterize lymph node morphology, specifically evaluating cortical thickness, uniformity, size, shape (round vs. oval), and vascularity patterns 2, 1. This imaging determines whether the lymphadenitis is reactive/infectious versus malignant, which fundamentally changes management.
Tissue Diagnosis Requirements
- Ultrasound-guided fine needle aspiration (FNA) or core biopsy is required when ultrasound reveals suspicious features to establish the definitive diagnosis 1, 3
- Culture of lymph node aspirate is essential to identify specific infectious organisms (mycobacterial, bacterial, or fungal) 4, 5
- Histological examination differentiates between infectious lymphadenitis, granulomatous disease, and malignancy 6, 5
Treatment Based on Etiology
Infectious Lymphadenitis
For mycobacterial infections (including BCG-induced or non-tuberculous mycobacteria):
- Conservative management with observation is preferred initially, as many cases resolve spontaneously 4, 7
- Avoid primary surgical drainage or excision due to extremely high complication rates (45% in surgical series), including wound dehiscence, infection, and cutaneous sinus formation 7
- Needle aspiration is the preferred intervention if drainage is required, rather than open surgery 7
- Antimycobacterial therapy is indicated for confirmed tuberculosis reactivation 5
For BCG vaccine-induced axillary lymphadenitis specifically:
- Primary surgical treatment should be avoided as initial management due to high fistulization rates and poor wound healing 7
- Surgery should be confined only to cases where diagnosis is uncertain or for managing suppurative complications 7
Self-Limited Conditions
Kikuchi-Fujimoto disease (histiocytic necrotizing lymphadenitis) requires differentiation from malignant lymphoma through biopsy, but treatment is supportive as it is self-limited 6. This distinction is critical because treatment approaches and prognosis differ dramatically from lymphoma.
Follow-Up Protocol
For benign lymphadenitis after biopsy confirmation:
- Ultrasound monitoring every 6 months for 1-2 years to ensure stability 1
- Re-biopsy is indicated if changes occur in lymph node size, morphology, or cortical features during surveillance 1
Additional Imaging Considerations
- PET/CT should be considered if there is concern for lymphoma or other non-breast malignancy 1
- CT chest/abdomen/pelvis may be warranted to evaluate for primary malignancy if metastatic disease is suspected 1
Critical Pitfalls to Avoid
- Never proceed with surgical excision before establishing diagnosis, as this leads to unnecessary morbidity in infectious cases 7
- Do not assume malignancy without tissue diagnosis, as benign infectious causes (mycobacterial, BCG-induced) can mimic malignant lymphadenopathy radiographically 4, 6, 5, 8
- Consider BCG vaccination history even with long latent periods (up to 8 months), particularly in adults who have traveled to regions where BCG vaccination is routine 8
- In HIV-positive patients, surgical complications are significantly higher, making conservative management even more critical 7