In a child with painless right cervical level II‑III lymphadenopathy and multiple fat‑laden lymph nodes, the largest measuring 4 × 1.9 × 4.4 cm, and no fever, what is the appropriate evaluation and management?

Evaluation and Management of Painless Cervical Lymphadenopathy with Fat-Laden Lymph Nodes in a Child

This child requires excisional biopsy of the largest cervical lymph node for definitive diagnosis, with nontuberculous mycobacterial (NTM) lymphadenitis being the most likely diagnosis given the painless, unilateral presentation and fat-laden appearance on imaging. 1

Primary Diagnostic Consideration: Nontuberculous Mycobacterial Lymphadenitis

The clinical presentation strongly suggests NTM lymphadenitis based on several key features:

• NTM cervical adenitis accounts for approximately 80% of culture-proven mycobacterial lymphadenitis in children aged 1-5 years, presenting characteristically as unilateral, non-tender cervical adenopathy that develops insidiously without systemic symptoms such as fever. 1, 2

• The unilateral presentation in 95% of NTM cases matches this patient's right-sided involvement of levels II and III. 1, 3

• The absence of fever, pain, and systemic symptoms distinguishes NTM from acute bacterial lymphadenitis, which presents with rapid onset, warmth, erythema, localized tenderness, and fever. 2

• Fat-laden lymph nodes on imaging suggest chronic inflammatory changes rather than acute bacterial infection or aggressive malignancy. 4

Immediate Diagnostic Workup

Essential Testing Before Biopsy

• Tuberculin skin test (PPD) must be performed to differentiate tuberculous infection from NTM disease, as this distinction fundamentally changes treatment and requires public health notification if tuberculosis is confirmed. 1, 2

• Chest radiography is necessary to exclude intrathoracic involvement or active tuberculosis. 1

• Complete blood count with differential, ESR, and CRP should be obtained; NTM typically shows normal or mildly elevated inflammatory markers without leukocytosis. 2

Imaging Considerations

• Neck ultrasound is the preferred initial imaging modality because it avoids ionizing radiation and can assess nodal architecture, margins, and perinodal fat changes. 1, 4

• Perinodal fat hyperechogenicity, heterogeneous echotexture, and loss of fatty hilum are significant ultrasound findings that help differentiate causes of cervical lymphadenopathy in children. 4

Risk Stratification for Malignancy

While NTM is most likely, malignancy must be excluded given the size and persistence:

• A lymph node ≥1.5 cm that has persisted for ≥2 weeks without significant fluctuation places a child at increased risk for malignancy or chronic infection. 1

• Size >2 cm, fixed or firm consistency, and supraclavicular location are high-risk features for malignancy. 2, 5

• Large lymph nodes (this patient's largest measures 4.4 cm) warrant definitive tissue diagnosis regardless of clinical suspicion. 5

Definitive Management: Excisional Biopsy

Complete surgical excision of the affected lymph node without adjunctive chemotherapy is the treatment of choice for NTM lymphadenitis, with a success rate of approximately 95%. 1, 2

Critical Technical Points

• Excisional biopsy (complete node removal) is mandatory rather than incisional or core biopsy, as incomplete removal markedly increases the risk of sinus formation and chronic drainage. 1

• Fine-needle aspiration (FNA) alone is generally not suitable for initial diagnosis because it often yields insufficient tissue for definitive histopathologic classification and cannot reliably exclude malignancy in children. 1, 5

• The excised tissue must be sent for: histopathology, mycobacterial culture (both tuberculosis and NTM), and routine bacterial culture. 6, 1

Alternative Management for High Surgical Risk

• For lymph nodes ≥5 cm or those in difficult anatomical sites where surgical risk is high, a clarithromycin-based multidrug regimen combined with corticosteroids may be considered, though evidence is limited. 1

• However, given this patient's node size (4.4 cm) and accessible location (levels II-III), surgical excision remains the preferred approach. 1

Critical Pitfalls to Avoid

• Never prescribe empiric antibiotics in the absence of signs suggesting acute bacterial infection (rapid onset, fever, tenderness, overlying erythema), as this delays definitive diagnosis and is ineffective for NTM. 1, 2

• Do not assume partial resolution after antibiotics excludes malignancy; infection may occur in underlying malignancy. 2

• If PPD is strongly positive (≥15 mm), initiate empiric anti-tuberculous therapy while awaiting culture results, especially if additional risk factors exist (family history of TB, birth abroad). 1

• Distinguish tuberculosis from NTM, as only approximately 10% of culture-proven mycobacterial cervical lymphadenitis in children is tuberculosis, but this distinction is critical for treatment and public health tracking. 1, 2

Follow-Up Strategy

• After surgical excision for NTM adenitis, monitor for recurrence; a second surgical intervention is typically required if disease recurs. 1

• If the lymph node completely resolves (unlikely without intervention given size and duration), schedule one additional follow-up in 2-4 weeks to monitor for recurrence. 1

• If cultures confirm tuberculosis, discontinue NTM-directed therapy, initiate standard anti-tuberculous treatment, and notify public health authorities. 1, 2