What is the appropriate assessment and management plan for a young adult female with a one‑week history of right neck swelling diagnosed as viral lymphadenopathy, now presenting with bilateral conjunctival injection (viral conjunctivitis), a left submandibular lymph node, and currently on amoxicillin/clavulanate?

Assessment and Management Plan

This patient presents with bilateral conjunctivitis and cervical lymphadenopathy in the context of a recent viral upper respiratory infection; the bilateral eye redness is most consistent with viral conjunctivitis requiring supportive care only, while the neck mass warrants close observation without additional antibiotics given the absence of current signs of bacterial infection. 1

Immediate Assessment

Conjunctivitis Evaluation

• Viral conjunctivitis is the most common cause of infectious conjunctivitis (80% of cases) and typically presents with bilateral involvement, serofibrinous discharge, and preauricular lymphadenopathy. 2, 3
• The patient's bilateral eye redness developing after systemic viral symptoms, combined with cervical lymphadenopathy, strongly suggests viral etiology rather than bacterial conjunctivitis. 2
• Bacterial conjunctivitis would more likely present with mattering/adherence of eyelids on waking and purulent discharge, which are not described here. 2

Neck Mass Risk Stratification

• The American Academy of Otolaryngology-Head and Neck Surgery recommends evaluating for signs of bacterial infection including warmth, erythema, localized swelling, and tenderness to palpation. 1
• Current examination shows a palpable left submandibular mass without fever (temperature 36.3°C), without overlying erythema, and with resolution of the initial neck pain—these findings do NOT support active bacterial infection. 1
• The mass has been present for 1 week, which places it at the threshold where persistence becomes concerning. 1

Management Plan

For Viral Conjunctivitis

• No antibiotic treatment is indicated for viral conjunctivitis, as approximately 80% of cases are caused by adenovirus and are self-limiting. 2, 3
• Provide supportive care with cool compresses and artificial tears for symptom relief. 2
• Educate patient on strict hand hygiene and avoiding touching eyes to prevent transmission, as viral conjunctivitis spreads easily. 3
• Expected duration: symptoms typically resolve within 1-2 weeks without specific antiviral therapy. 2

For Cervical Lymphadenopathy

• The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends AGAINST prescribing additional antibiotics without evidence of ongoing bacterial infection. 1
• The patient is already on co-amoxiclav 625mg q8h, which was appropriate initial empiric therapy when bacterial infection was suspected. 1, 4
• Discontinue the co-amoxiclav, as there are no current signs of bacterial infection (afebrile, no erythema, no warmth, pain resolved). 1
• Reactive cervical lymphadenopathy from viral respiratory infections typically resolves within days to weeks of the infectious symptoms. 1

Follow-Up Strategy

• Schedule reassessment in 2 weeks to evaluate for complete resolution, persistence, or progression of the lymph node. 1
• At 2-week follow-up, assess for:
  • Complete resolution (if so, schedule one additional follow-up in 2-4 weeks to monitor for recurrence) 1
  • Persistence without resolution (proceed to imaging and specialist referral) 1
  • Concerning features: fixation to adjacent tissues, firm consistency, size >1.5 cm, or ulceration 1

Critical Decision Points

When to Escalate Care

Refer to otolaryngology immediately if: 1

• Lymph node persists ≥2 weeks without complete resolution
• Development of concerning physical characteristics (fixed, firm >1.5 cm, ulcerated, supraclavicular location)
• New systemic symptoms (fever, night sweats, weight loss)
• Failure of lymph node to decrease in size over the 2-week observation period

Imaging Indications

• If the mass persists at 2-week follow-up, order contrast-enhanced CT or MRI of the neck before specialist referral. 1
• The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that most adult neck masses are neoplastic rather than infectious, making vigilant follow-up essential. 1

Important Caveats

Antibiotic Stewardship

• Continuing antibiotics without signs of bacterial infection delays diagnosis of potential malignancy and contributes to antimicrobial resistance. 1
• The initial diagnosis of "viral lymphadenopathy" with antibiotic prescription was inconsistent with viral etiology—viral infections do not require antibiotics. 1

Red Flags to Monitor

• Partial resolution of lymphadenopathy may represent infection in an underlying malignancy and requires continued evaluation until complete resolution. 1
• Even if imaging appears benign, continued evaluation is necessary until definitive diagnosis is obtained. 5
• The shift from right-sided neck swelling initially to left submandibular mass on examination requires clarification—bilateral or migratory lymphadenopathy increases concern for systemic disease. 1

Conjunctivitis Precautions

• Advise patient to avoid contact lens wear until conjunctivitis completely resolves. 2
• If symptoms worsen, develop severe pain, or vision changes occur, urgent ophthalmology evaluation is needed to rule out herpes simplex virus, which would require specific antiviral therapy. 6