What is the appropriate management for a patient presenting with unilateral cervical lymphadenopathy and mild eczematous changes, without fever?

Management of Unilateral Cervical Lymphadenopathy with Mild Eczematous Changes, Without Fever

In a patient with unilateral cervical lymphadenopathy and mild eczematous changes without fever, the priority is to avoid empiric antibiotics and schedule close follow-up within 2 weeks, while treating the eczema with emollients and low-potency topical corticosteroids, and maintaining high suspicion for nontuberculous mycobacterial (NTM) infection if the lymph node persists beyond 2-4 weeks. 1, 2

Immediate Assessment and Red Flag Exclusion

Rule Out Kawasaki Disease

• Although Kawasaki disease classically presents with fever ≥5 days plus cervical lymphadenopathy ≥1.5 cm, the absence of fever makes this diagnosis unlikely 3, 2
• Kawasaki disease requires bilateral non-purulent conjunctivitis, oral changes (cracked lips, strawberry tongue), polymorphous rash, or extremity changes—not mild eczematous changes 3

Assess for Acute Bacterial Infection

• Do NOT prescribe empiric antibiotics in the absence of signs suggesting acute bacterial infection: rapid onset, fever, tenderness, warmth, or overlying erythema 2, 4
• The absence of fever and acute inflammatory signs argues strongly against bacterial lymphadenitis requiring antibiotics 5, 6

Management of Eczematous Changes

Topical Treatment

• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 3
• Use the least potent topical corticosteroid required to control the eczema, such as 1% hydrocortisone applied to affected areas 3-4 times daily 3, 7
• Avoid soaps and detergents; use a dispersible cream as a soap substitute 3

Monitor for Secondary Infection

• Look for crusting or weeping suggesting bacterial superinfection of eczema 3
• Grouped, punched-out erosions or vesiculation indicate herpes simplex infection requiring virological screening 3

Lymphadenopathy Follow-Up Strategy

Two-Week Reassessment

• Schedule follow-up within 2 weeks to evaluate for resolution, progression, or persistence of the lymph node 1, 2, 4
• Document the size, consistency (fixed vs. mobile), and any changes in the lymph node 2, 4

If Lymph Node Persists at 2 Weeks

• Proceed immediately to definitive workup if the lymph node has not completely resolved, as partial resolution may represent infection in an underlying malignancy 1, 2
• A lymph node ≥1.5 cm persisting ≥2 weeks without significant fluctuation places the patient at increased risk for malignancy or chronic infection 1, 2

Consider NTM Infection

• Unilateral cervical lymphadenopathy without fever is highly characteristic of NTM lymphadenitis, particularly in children aged 1-5 years 1, 2
• NTM lymphadenitis occurs in 95% of cases as unilateral disease and is generally not tender 1
• If the lymph node persists beyond 4 weeks, strongly consider NTM infection and arrange tuberculosis testing (PPD or interferon-gamma release assay) 1

Definitive Workup if Lymph Node Persists

Imaging and Laboratory Studies

• Obtain baseline inflammatory markers: ESR, CRP, CBC with differential 2
• Consider contrast-enhanced CT or MRI for lymph nodes in difficult anatomical sites or if malignancy risk is elevated 1, 2

Tissue Diagnosis

• Excisional biopsy is the treatment of choice for NTM lymphadenitis, with a success rate of approximately 95% 1, 2
• Fine-needle aspiration (FNA) may be used for initial evaluation but has limitations compared to excisional biopsy 1, 2
• For NTM lymphadenitis, excisional surgery alone (without chemotherapy) is recommended, avoiding incision and drainage which can lead to chronic fistula formation 1

Critical Pitfalls to Avoid

• Never prescribe multiple courses of antibiotics without clear bacterial infection signs, as this delays diagnosis of malignancy or chronic infection 2, 4
• Do not assume reactive lymphadenopathy from a viral upper respiratory infection if the node persists beyond 2 weeks after symptom resolution 1, 4
• Never assume a persistent neck mass is benign without definitive diagnosis, especially if it has not completely resolved at follow-up 2
• Avoid incision and drainage for suspected NTM lymphadenitis, as this leads to chronic draining sinuses; excisional biopsy is curative 1