What is the initial management approach for a patient presenting with unilateral neck lymph node swelling, fever, and chills?

Initial Management of Unilateral Neck Lymph Node Swelling with Fever and Chills

Do not prescribe antibiotics empirically unless there are clear signs of acute bacterial infection (warmth, erythema of overlying skin, localized tenderness, recent upper respiratory infection, or dental problem), and instead prioritize urgent evaluation for life-threatening conditions and malignancy within 2 weeks. 1, 2

Immediate Life-Threatening Assessment (First 24-48 Hours)

Urgently evaluate for Kawasaki disease if fever has persisted ≥5 days with unilateral cervical lymphadenopathy ≥1.5 cm, specifically examining for: 1, 2

• Bilateral nonexudative conjunctivitis
• Oral changes (cracked lips, strawberry tongue, pharyngeal erythema)
• Polymorphous rash
• Extremity changes (erythema or edema of hands/feet)

If ≥4 of 5 principal features are present with fever, diagnose Kawasaki disease and initiate IVIG within 36 hours to prevent coronary artery complications. 1 Infants <6 months require especially high suspicion as they have the highest risk of coronary complications. 1, 2

Initial Clinical Evaluation

Document the following specific details: 2

• Fever duration and pattern: Exact number of days with fever, temperature peaks
• Constitutional symptoms: Night sweats, unexplained weight loss (>10% body weight), performance status decline
• Lymph node characteristics: Size (measure in cm), consistency (firm vs. fluctuant), mobility (fixed vs. mobile), tenderness, overlying skin changes
• Infectious exposures: Recent upper respiratory infection, dental problems, tuberculosis contacts, animal exposures (cats, soil/water contact), tick bites
• Risk factors: HIV risk factors, immunosuppression, tobacco/alcohol use, age >40 years

Physical examination should specifically assess for: 3, 2

• Supraclavicular nodes (always suspicious for malignancy)
• Multiple levels of cervical adenopathy
• Signs of deep involvement: trismus, reduced tongue protraction, earache
• Parotid swelling (consider Sjögren's-associated lymphoma if present) 4

Initial Laboratory Workup

Obtain baseline studies: 1, 2

• CBC with differential: Look for leukocytosis (bacterial), lymphocytosis (viral), or atypical lymphocytes
• ESR and CRP: Elevated inflammatory markers
• Tuberculin skin test (PPD): Especially if unilateral, non-tender node in child aged 1-5 years or adult with TB exposure 3

Decision Point: Antibiotic Trial vs. Immediate Further Workup

Only prescribe antibiotics if ALL of the following bacterial infection signs are present: 1, 2

• Warmth and erythema of overlying skin
• Localized tenderness
• Fever with tachycardia
• Recent upper respiratory infection or dental problem

If antibiotics are prescribed, reassess within 2 weeks—if the mass has not completely resolved, proceed immediately to malignancy workup as partial resolution may represent infection in underlying malignancy. 1, 2 Do not prescribe multiple courses of antibiotics without clear bacterial signs, as this delays cancer diagnosis. 1, 2

Urgent Referral Criteria (Within 2 Weeks)

Refer to otolaryngology urgently if any of the following are present: 2

• Lymphadenopathy persists ≥2 weeks without significant fluctuation
• Lymph node size >2 cm or ≥1.5 cm persisting >2 weeks 3, 1
• Supraclavicular location (always suspicious)
• Fixed, firm, or ulcerated nodes 3
• Multiple levels of adenopathy
• Failure to resolve after appropriate antibiotic course

Imaging Strategy

Initial imaging approach: 1, 2

• Ultrasound: First-line for characterizing lymph node architecture and differentiating solid from cystic lesions
• Contrast-enhanced CT neck/chest: If malignancy suspected, to assess extent and identify primary tumor
• MRI: For detailed soft tissue assessment in complex cases

Special Populations and Differential Considerations

Children aged 1-5 years with unilateral, non-tender cervical node: 3

• Nontuberculous mycobacterial (NTM) lymphadenitis is most likely (95% unilateral, 80% due to MAC)
• Obtain PPD (may be weakly positive or negative in NTM)
• Excisional biopsy without chemotherapy is treatment of choice with 95% success rate
• Do not treat empirically with antibiotics, as this delays definitive surgical management

Adults with persistent unilateral node and systemic symptoms: 4

• Consider lymphoma, especially if accompanied by unexplained weight loss, night sweats, or parotid swelling (Sjögren's-associated lymphoma risk 5-18%)
• Proceed to tissue diagnosis without delay

Tick exposure or endemic area: 4

• Consider tularemia (ulceroglandular form): Look for skin ulcer/eschar at entry site with tender regional adenopathy
• If suspected, treat with streptomycin 30 mg/kg/day in 2 divided doses or gentamicin 3-5 mg/kg/day for 7-10 days before confirmation

Tissue Diagnosis Strategy

When tissue diagnosis is required: 1, 2

• Fine-needle aspiration (FNA): Preferred initial method (positive predictive value 91.3% for benign, 75% for malignant)
• Excisional biopsy: Perform if FNA non-diagnostic or lymphoma suspected (diagnostic yield >95%)
• Send tissue for histology, immunophenotyping, cytogenetic/molecular analysis, and mycobacterial culture

Critical Pitfalls to Avoid

• Never assume a persistent neck mass is benign without definitive diagnosis 1
• Do not prescribe multiple antibiotic courses without clear bacterial signs—this is the most common cause of delayed cancer diagnosis 1, 2
• Do not wait beyond 2 weeks for persistent lymphadenopathy without initiating definitive workup 3, 1, 5
• Never miss Kawasaki disease in a child with ≥5 days of fever—coronary complications can be prevented with timely IVIG 1, 2