Evaluation and Management of an 11-Year-Old with Unilateral Nipple Enlargement and Cervical Lymphadenopathy
This presentation requires urgent evaluation to distinguish physiologic pubertal changes from serious pathology, particularly nontuberculous mycobacterial (NTM) lymphadenitis or malignancy.
The cervical lymphadenopathy is the primary concern and should drive the evaluation, while the unilateral nipple enlargement is likely physiologic gynecomastia common in early puberty but requires assessment to exclude pathologic nipple discharge.
Initial Assessment: Cervical Lymphadenopathy
Critical History Elements
Duration and progression: Lymphadenopathy persisting ≥2 weeks without significant fluctuation places the child at increased risk for malignancy or chronic infection 1, 2.
Acute bacterial features: Assess for rapid onset, fever, warmth, erythema of overlying skin, and localized tenderness—their absence makes viral etiology or chronic infection (particularly NTM) more likely 2, 3.
Constitutional symptoms: Unexplained weight loss, night sweats, and persistent fever suggest malignancy or systemic disease rather than simple viral illness 2, 4.
Exposure history: Children aged 1-5 years are at peak risk for NTM cervical adenitis due to frequent contact with soil and water sources, though this 11-year-old remains at risk 1, 2.
Physical Examination Characteristics
Size: Lymph nodes ≥1.5 cm warrant closer monitoring and increase malignancy risk 1, 2.
Consistency and mobility: Fixed, firm, or matted nodes are highly suspicious and warrant immediate investigation 1, 2, 4.
Location: Supraclavicular or posterior cervical lymphadenopathy carries much higher risk for malignancies than anterior cervical lymphadenopathy 5, 6.
Laterality: Unilateral presentation is typical for NTM lymphadenitis (95% of cases) and also raises concern for malignancy 1, 2.
Initial Assessment: Nipple Enlargement
Distinguish Physiologic from Pathologic
Assess for nipple discharge: Determine if discharge is present, and if so, whether it is spontaneous or requires manipulation 7, 8.
Pathologic discharge characteristics: Spontaneous, unilateral, single-duct, bloody, or serous discharge requires imaging evaluation even in children 7, 8.
Physiologic presentation: Unilateral breast enlargement without discharge in an 11-year-old is most consistent with normal pubertal gynecomastia and requires only reassurance 8.
Management Algorithm
Step 1: Immediate Evaluation (Do Not Delay)
Avoid empiric antibiotics in the absence of acute bacterial features (rapid onset, fever, tenderness, erythema), as multiple antibiotic courses without clear infectious etiology significantly delay cancer diagnosis 1, 2.
Step 2: Tuberculosis Testing
Perform PPD tuberculin skin test or interferon-gamma release assay (IGRA) to distinguish tuberculosis from NTM, as this fundamentally changes treatment and requires public health notification 1, 2.
If PPD is strongly positive with granulomatous disease, consider anti-TB therapy while awaiting lymph node culture results 1.
Step 3: Imaging Evaluation
Ultrasound is the initial imaging modality for cervical lymphadenopathy in children to assess node characteristics, size, and vascularity 2, 9.
For larger lymph nodes (≥5 cm) or those in difficult anatomical sites, consider MRI or CT 1.
Step 4: Follow-Up Assessment at 2 Weeks
If the lymph node has not completely resolved, proceed to definitive workup, as partial resolution may represent infection in an underlying malignancy 1, 2.
If completely resolved, schedule one additional follow-up in 2-4 weeks to monitor for recurrence 1.
Definitive Diagnosis and Treatment
When to Proceed to Biopsy
Lymphadenopathy persisting >4 weeks without resolution requires tissue diagnosis 1, 4.
Fine-needle aspiration (FNA) may be used for initial evaluation but has limitations; excisional biopsy provides definitive diagnosis 1, 4.
NTM Lymphadenitis Management
Complete surgical excision is the treatment of choice for NTM lymphadenitis in children, with a success rate of approximately 95% 1, 2.
For larger or difficult-to-resect nodes, clarithromycin multidrug regimen combined with corticosteroids may reduce disseminated disease risk 1.
Malignancy Considerations
Risk factors include: Age >10 years (increasing risk), size ≥1.5 cm persisting >2 weeks, fixed/firm consistency, supraclavicular location, and constitutional symptoms 1, 2, 4.
Excisional biopsy is required for definitive diagnosis if malignancy is suspected 4, 6.
Nipple Enlargement Management
If No Pathologic Discharge Present
Reassure that unilateral gynecomastia is common in early puberty and typically resolves spontaneously 8.
Educate patient and family to report development of any spontaneous discharge, particularly if bloody or serous 8.
If Pathologic Discharge Present
Ultrasound is the initial examination for children under 30 years with pathologic nipple discharge 8.
Mammography is not routinely recommended in children due to dense breast tissue limiting sensitivity and extremely low breast cancer risk 8.
Critical Pitfalls to Avoid
Do not prescribe multiple courses of antibiotics without clear infectious etiology, as this significantly delays cancer diagnosis 1, 2.
Do not mistake NTM lymphadenitis for bacterial infection—children may present with only fever and unilateral enlarged cervical lymph node, which can be mistakenly treated as bacterial lymphadenitis 1.
Do not use corticosteroids without appropriate diagnosis, as they can mask histologic diagnosis of lymphoma or other malignancy 4, 6.
Consider Kawasaki disease if fever ≥5 days with cervical lymphadenopathy ≥1.5 cm, even if other classic features are not initially present 1, 2.