Cervical Lymphadenopathy Without Fever in a 6-Year-Old Child
Most Likely Causes
In a 6-year-old child with cervical lymphadenopathy without fever, the most common cause is reactive lymphadenopathy from a recent or ongoing viral infection, followed by nontuberculous mycobacterial (NTM) infection, which characteristically presents without systemic symptoms. 1, 2
Primary Differential Diagnosis
Reactive/viral lymphadenopathy is the most common cause, affecting up to 90% of children aged 4-8 years, and typically represents a transient response to benign local or generalized infection 1, 2
Nontuberculous mycobacterial (NTM) lymphadenitis is particularly important in this age group (peak incidence 1-5 years) and characteristically occurs insidiously without systemic symptoms—the involved nodes are generally unilateral (95%), not tender, and rarely associated with fever 3, 4
Kawasaki disease must be considered if the child has had fever for ≥5 days at any point, even if fever has resolved, as cervical lymphadenopathy ≥1.5 cm can be the presenting and most prominent sign, especially in older children 3, 4
Cat-scratch disease and toxoplasmosis are common causes of subacute or chronic lymphadenitis without prominent fever 2, 5
Critical Assessment Points
Node Characteristics That Matter
Size ≥1.5 cm that persists ≥2 weeks without significant fluctuation places the child at increased risk for malignancy or chronic infection 4
Unilateral presentation (95% of cases) strongly suggests NTM lymphadenitis rather than viral causes, which are typically bilateral 3, 4
Supraclavicular or posterior cervical location carries much higher risk for malignancies than anterior cervical lymphadenopathy 2, 6
Fixed, firm, or ulcerated nodes are suspicious and warrant immediate further investigation 4
Key Historical Features
Duration of symptoms: Reactive lymphadenopathy from respiratory infections typically resolves within days of completing treatment or with resolution of infectious symptoms 4
Absence of fever makes acute bacterial lymphadenitis (Staphylococcus aureus, Group A Streptococcus) less likely, as these typically present with rapid onset, fever, tenderness, and overlying erythema 4, 2
Exposure history: Contact with cats (cat-scratch disease), soil/water exposure (NTM), or tuberculosis exposure must be assessed 3, 2
Recent fever history: Even if currently afebrile, determine if fever occurred in the preceding 5-10 days to evaluate for Kawasaki disease 3
Diagnostic Approach
Initial Workup
Do not initiate empiric antibiotics in the absence of signs suggesting acute bacterial infection (rapid onset, fever, tenderness, overlying erythema), as this is a common pitfall that can mask underlying diagnoses like NTM or Kawasaki disease 4
Essential Testing
Tuberculin skin test (PPD) should be performed in all patients with suspected mycobacterial lymphadenitis to distinguish tuberculosis (requires public health tracking and drug therapy) from NTM 3, 4
Chest radiograph to exclude tuberculosis and evaluate for intrathoracic adenopathy 3, 7
Complete blood count, inflammatory markers (ESR, CRP), albumin, and liver enzymes if Kawasaki disease is being considered or if the node has persisted ≥2 weeks 3, 4
Imaging Considerations
Ultrasound is the preferred initial imaging modality as it is non-radiating and can help differentiate NTM from bacterial lymphadenitis by assessing nodal architecture, margins, and shape 4, 6
Contrast-enhanced CT typically shows asymmetric adenopathy with ring-enhancing masses in NTM lymphadenitis, with minimal inflammatory stranding of subcutaneous fat 3
Management Algorithm
If Node Completely Resolves
- Schedule one additional follow-up in 2-4 weeks to monitor for recurrence 4
If Node Persists or Enlarges After 2 Weeks
Proceed to definitive workup, as partial resolution may represent infection in an underlying malignancy 4
For suspected NTM lymphadenitis: Complete surgical excision without chemotherapy is the treatment of choice, with approximately 95% success rate 3, 4, 7
Avoid incisional biopsy alone for suspected NTM, as this increases risk of fistula formation and chronic drainage 7
For nodes ≥5 cm or in difficult anatomical sites: Consider clarithromycin-based multidrug regimen in combination with corticosteroids if surgical risk is high 4
Critical Pitfalls to Avoid
Mistaking NTM for bacterial adenitis: Children may present with only an enlarged cervical node, and subsequent rash/mucosal changes after antibiotic administration are mistaken for drug reaction rather than recognizing the underlying diagnosis 3, 4
Missing Kawasaki disease: Cervical lymphadenopathy can be the presenting and most prominent sign, leading to misdiagnosis as bacterial lymphadenitis—always inquire about fever history in the preceding 5-10 days 3
Premature reassurance: A lymph node ≥1.5 cm persisting ≥2 weeks requires definitive workup even if the child appears well 4, 6