Benign Pediatric Cervical Lymphadenopathy
Jayson Greenberg, M.D.
November 16, 2000

Neck masses are common findings in pediatric patients. They come in three basic types: congenital, inflammatory, and malignant. Cervical lymph nodes are weigh stations of lymphatic drainage. They are divided into several anatomical groups that we all know very well. The anterior triangle drains the face, nasopharynx, oral cavity and oropharynx. These nodes are commonly identified in cervical lymphadenitis, while the supraclavicular and posterior triangle nodes are involved less commonly. These posterior nodes involve a different drainage pattern and usually reflect systemic disease. Palpable nodes are a common finding in children, about 40% of infants less than one year old can have palpable lymph nodes, and 55 % of children overall have palpable nodes in the absence of infection or systemic illness. The majority of inflamed nodes are due to upper respiratory tract infections, and the majority of these are viral and bacterial. They usually appear rapidly and resolve spontaneously or with antibiotics.

History focuses on the onset and duration of symptoms. Is there any fever? Are there any constitutional symptoms like weight loss or fatigue? What has the rate of lymph node enlargement been? Has the patient been on antibiotics and has there been any response to antibiotics? Is there any exposure to animal bites or scratches? What is the PPD status? Is there any contact with tuberculosis? Any recent travel history? Or any HIV risk factors?

On physical exam, are the nodes small, discrete, mobile and nontender? Are they bilateral? Is there a unilateral, large warm tender node? Is there any surrounding cellulitis? Are there any overlying skin changes? Is there any fluctuance? Are there any systemic signs present such as generalized lymphadenopathy or hepatosplenomegaly?

In viral lymphadenitis, the lymph nodes are usually small and soft. There is a high propensity for bilateral disease. There are usually no overlying skin changes, and these nodes are rarely suppurative. In general, viral infections are of shorter duration, self-limited, and there is usually a spontaneous resolution. Some more common viral agents are Epstein-Barr virus, which is usually associated with a tonsillopharyngitis-type picture and cytomegalovirus, in which more systemic signs, such as hepatosplenomegaly or rash, are seen.

Bacterial lymphadenitis is by far the most common etiology, and is most often due to upper respiratory tract infections that seed the regional lymph nodes. This is typically seen in very young children, ages one to four. The most common organisms are penicillin-resistant staph and group A beta hemolytic strep, which are involved in up to 80% of cases. This entity is usually diagnosed easily with history and physical examination. These nodes are usually rapidly developing. There is associated fever and constitutional symptoms as well as a recent sore throat or cough. On examination, the lymph nodes are tender, warm, and erythematous. The most commonly involved sites are the submandibular region and high jugulodigastric nodes. About one-quarter of these are fluctuant on presentation, and fluctuance is more commonly associated with a staph infection. Usually with the laboratory values there is a lymphocytosis with a left shift.

Brook, in 1987, reviewed 36 neck abscesses. The majority of these were aerobic but 14% were anaerobic and a small percentage were mixed. He found the mixed infections were a little more virulent. There was also a significant amount of beta-lactamase producing Staphylococcus aureus, about 50%. Hawkins and Austin, in 1991, reviewed 112 patients, all less than 5 years old. The majority of these involved the anterior triangle and the majority of organisms were staph and group A beta hemolytic strep with a smaller amount of anaerobes.

In bacterial lymphadenitis, if left untreated, lymph nodes will progressively enlarge. There will be some surrounding cellulitis and there may develop fluctuance with spontaneous drainage. The initial treatment of choice is antibiotics. One needs to consider beta-lactamase resistance usually in the young children who are quite toxic-appearing when they are admitted. Improvement is usually seen in two to three days, although complete resolution may take weeks. A small percentage will go on to suppuration. Needle aspiration or incision and drainage can be used for these cases. Needle aspiration involves no generalized anesthetic and is less traumatic. There is no scar, and this method is therapeutic and diagnostic. However, incision and drainage is ultimately the best way to break up all the loculations. Brodsky et al, in 1992, studied needle aspirations in 17 patients. This is not randomized or controlled but these patients underwent needle aspiration with an 18 or 20 gauge needle and a 10cc syringe. If they were unchanged, they underwent repeated aspiration, and if they were worse, they underwent a formal incision and drainage. They had ten responders who were treated with incision and drainage and eight non-responders. Those patients who were non-responders were more likely to have a multilocular abscess. Those patients that had a larger volume abscess were more likely to fall into the non-responsive group.

While the diagnosis of acute bacterial lymphadenitis is relatively easy, the more challenging diagnosis comes in a more chronic picture when a patient has enlarged, minimally tender, slightly fluctuant nodes. There has not been any prodrome or associated symptoms and, the patient has already had a full course of antibiotics and has not gotten any better. The most common organism implicated here in this picture here is Mycobacterium, which comes in two types: tuberculous and atypical. This accounts for about 10% of pediatric cervical lymphadenitis.

“Scrofula,” which is Latin for glandular swelling, dates back to about 3000 years and was noted in the writings in Hippocrates. Prior treatments include the royal touch: the monarchs of the medieval era used to touch these patients to cure them. This was started by Clovis I of France and continued well into the 19 th century. Louis the XVI claimed to have touched 2,400 patients without any long term follow-up. Digitalis and Lugol solution were also used. In 1882, Robert Koch discovered the tuburcle bacillus. At the turn of the century, the two major pathogens identified were M-tuberculosis and M-bovis, although, with the pasteurization of milk, bovis is no longer a significant factor.

By the 1950s nontuberculous mycobacteria had been recognized as a cause of cervical lymphadenitis. Mycobacteria, in general, are obligate aerobes. They are difficult to stain and are resistant to decoloration by acid or alcohol and are hence termed acid fast. There are 50 species, about half of which are pathogenic in man. Cervical lymphadenitis is the most common manifestation of nontuberculous mycobacteria in healthy children. The incidence is difficult to estimate, since probably only 25% of cases are reported. This organism is found most commonly in soil, water, and milk. Most commonly implicated organisms are M-Avium-intracellulare, M-scrofula, and M-kansasii. About 90% of mycobacteria positive nodes in children ages 0-12 are from nontuberculous bacteria. This results from a localized infection from entrance to the oropharyngeal mucosa, perhaps through tooth eruption or young children placing contaminated objects in their mouth. There is no human to human transmission.

Usually these nodes have been present for weeks. They have a poor response to antibiotics. Half of these patients have had a prior course of antibiotics. These also tend to occur in younger patients. Wolinsky reviewed 100 patients that he had treated over 40 years. Eighty percent of these patients were less than 4 years old. There was a slight female predominance of 1.5% - 1% and it was more common in the winter. There was no prior TB exposure, no constitutional symptoms, and it typically appeared in immunocompetent patients. On physical examination, these nodes tend to be nontender and slightly fluctuant. They are unilateral, especially in the submandibular position. There is inflammation of the overlying skin as well. As the caseating necrosis advances, the skin becomes adherent and the skin turns a violet or reddish hue. If left untreated, a small percent will go on to rupture and fistula formation.

The PPD skin testing of these patients usually gets a moderate response of about 5-15mm of induration. There is some cross reactivity with the tuberculin protein. There are nontuberculous mycobacteria skin tests available, but these are not readily commercially available, and studies have shown a high rate of a blistering reaction to the point where some studies were actually discontinued. Chest x-ray is not routinely positive in these patients. There is a role for FNA, although isolation and identification can take several weeks and there is only about 50% culture recovery rate. The diagnosis in these patients is based on clinical suspicion. This is typically a younger child, age one to four with a unilateral, submandibular or high jugular node with overlying skin discoloration. There is a lack of systemic complaints, no history of TB, and an intermediate reactive PPD.

Treatment of mycobacterium is based on sensitivity to chemotherapeutic agents and nontuberculous mycobacterium in general are chemoresistant. There are anecdotal reports of successful treatment with chemotherapeutic drugs, and clarithromycin is shown to have some sensitivity with Mycobacterium avium-intracellulare. There are case reports of successful treatment with clarithromycin but the treatment is surgical excision. Excisional biopsy is therapeutic and diagnostic. A simple incision and drainage will result in sinus formation, studied at Baylor by Stewart, Coker, and Starke. They looked at 26 patients over 5 years. Fifteen patients had complete excision and of those 15, there was one recurrence. This is versus 11 that had incision and drainage or incisional biopsy, and 8 of those developed a sinus tract or recurrence. This difference is statistically significantly. Interestingly, of these successful complete excisions, these were done by 10 different surgeons. So the technique wasn’t necessarily as important as the need for gross total resection.

Curettage can be important in patients whose nodes are very close to the marginal mandibular branch of the facial nerve or when there is overlying extensive skin necrosis to avoid any kind of local flaps. Curettage is a staged procedure but it does involve a smaller incision, prevents skin loss and there is a decreased risk of facial nerve injury.

Tuberculous cervical lymphadenitis is the most common extrapulmonary presentation of TB and is seen in about 5%-10% of tuberculous children. It is more common in Asian and African-American individuals in an urban setting. It is much less common than atypical mycobacterium in children, although if there is a higher ratesof TB in certain areas, tuberculosis cervical lymphadenitis can account for up to 30% of cases. This is increasing in incidence in children, perhaps due to transmission from infected adults, since the overall the incidence of TB is also on the rise. Generally this results from extension from the paratracheal nodes or from the apical lung pleura and upper lung fields.

This is also a more chronic picture - however these children tend to be older children and adolescents. There is a history of previous TB exposure. A larger percentage will have some constitutional symptoms, but 50% of these patients are asymptomatic. HIV status is also very important since up to 50% of HIV patients will develop a mycobacterial infection.

On physical examination, the painless lymphadenopathy is more likely to be posterior. There is a greater propensity for bilateral involvement and scrofula is more prone to suppuration. About 85% of patients will have a positive skin test, which is defined as induration greater than 15 mm. Negative results are seen in those patients who are anergic from HIV or other immuno-compromised states. A skin test is simple with a high positive rate. A negative result in most cases will eliminate the diagnosis. A chest x-ray is also more important with these cases. It can be abnormal in 40%-60% of patients; however, not all of these patients have active pulmonary TB. The head and neck infection can be primary but in most cases is secondary to bronchial pulmonary involvement, and sputum culture can be positive in 20%. FNA shows epithelioid cells and multi-nucleoid cells. The AFB stain would be positive in up to 60% and the culture could be useful, but takes 4-6 weeks. On open biopsy, there are caseating granulomas that are consistent but not diagnostic. Two studies have looked at the role of FNA in adult patients. Lee et al looked at 29 FNAs; just under 70% had a positive AFB stain and culture and 24 were consistent with mycobacterial infection. Lau et al looked at the combination of FNA findings with a positive PPD and was able to diagnose 90% of patients with those two tests.

So with a positive PPD and histopathology, that is suggestive of Mycobacterium tuberculosis and most would advocate starting therapy. Treatment should be continued once the culture returns positive or even if it is negative, and the mass is responding to therapy. The primary therapy is medical because tuberculous cervical lymphadenitis is viewed as a local reaction of a systemic infection and modern chemotherapeutics work very well and can obviate the need for surgical incision. Most would advocate treating for about 6-8 months and usually the nodes will respond within three months. Surgery should be reserved for those patients that are culture negative and have no response to medical therapy or have persistent neck masses or draining sinuses despite full-course medical therapy. Excisional biopsy is preferred and all grossly involved lymph nodes should be removed.

Cat scratch disease was first described in France by Debray. In 1931, he treated a 10- year-old boy who had suppurative epitrochlear lymphadenitis. Debray thought this was TB but later found this patient slept with many cats, and in 1950 he wrote up his series. In 1983, Ware first described a pleomorphic gram-negative bacillus from cat scratch patients using the Warthin-Starry stain. English, five years later, isolated and identified the organism identical to those demonstrated in lymph nodes of cat scratch patients. And finally, Regenery, in 1992, isolated Bartonella-Hensley from the blood from a clinically-well cat and concluded that the cat was the reservoir for this disease.

Cat scratch disease occurs worldwide and in all races. It is more common in warm climates and appears to more be common in the fall and winter. Eighty percent of these patients are less than 21 years old. There are about 22,000 cases diagnosed yearly in the United States, and about one-tenth of these result in hospital admissions, although the actual incidence is probably higher since this disease is not reported.

Pathophysiologically, Bartonella-Hensley, is the causative organism. Cat contact is reported in 90% of cases. The scratch is reported less often, in about three-fourths of cases, and 25% have no history of a scratch of all. Zangwill et al performed a physician survey and identified 60 cat scratch patients that were compared with 56 age-matched cat-owning controls. They found that if you owned a kitten less than 12 months old, you were 15 times more likely to get cat scratch. If you were scratched or bitten you were 27 times more likely to get cat scratch. There is no human-to-human transmission, and this disease follows a very predictable course in an immunocompetent host.

Only a third of these patients have a fever and constitutional symptoms are seen in less than half of these patients. Physical exam focuses on the inoculation lesion as 60%-90% of these patients will develop about 3mm-5mm lesion about 3-10 days after the scratch. This typically will evolve to a papular pustule and it can persist for days to months, often being mistaken for an insect bite. Regional lymphadenopathy can be the only manifestation in half of the patients. The lymph nodes usually present about two weeks after inoculation and can persist for 60-70 days after the scratch. Most nodes appear proximal to the inoculation site, and since most scratches occur on the upper extremities or head and neck, the axillary and epitrochlear nodes are actually the most commonly involved nodes, followed by the cervical nodes. The overwhelming majority of these will regress in two to four months and a small amount will go on to suppuration.

Diagnosis can be made with the indirect fluorescent antibody test. This was looked at by Zangwill et al. Eighty-four percent of cat scratch patients were positive for this versus only 3.6% of controls. Bartonella IgM ELISA test can also be used. Studies have shown that levels of this Bartonella- IgM were significantly higher in cat scratch patients versus controls. PCR is less widely available, but is very sensitive and it can differentiate between different Bartonella species.

Histopathological findings are consistent but not pathognomonic. There are granulomatous stellate processes in a nonspecific inflammatory infiltrate. The key to making the diagnosis is the Warthin-Starry stain, which is best to identify the bacillus and best done within three to four weeks of illness. Culture is difficult, as this organism is very fastidious and difficult to isolate. Culture results take four to six weeks. Donnelly et al studied FNA using a modified silver stain and were able to identify the bacillus in just under 70% of aspirations.

No treatment is required for cat scratch. Usually the adenopathy recedes in two to four months. Incision and drainage should be avoided due to the high risk of a draining sinus. Some advocate needle aspiration to relieve painful lymphadenopathy and provide material for culture. Antibiotics have been studied, but this disease typically resolves with or without antibiotic therapy. Antibiotics may have a greater role in the immunocompromised patient and studies have shown in vitro sensitivity to the cat scratch bacillus from macrolides, tetracyclines, Rifampin, and third generation cephalosporins. There is intermediate sensitivity in aminoglycosides and Bactrim, and the cat scratch bacillus is resistant to first generation cephalosporins and fluoroquinolones. However, most studies are retrospective without adequate controls. One that is not is from Bass et al. This was a prospective, randomized, double-blind placebo controlled evaluation of azithromycin. They had 29 patients with serologically proven Bartonella infection, and they evaluated lymph node volume by ultrasound. This was done at entry into the study and then weekly. Their endpoint was time and days to 80% resolution of lymph node volume. Of those that took the azithromycin, 50% had an 80% decrease within 30 days. In the placebo group, only 1 of 15 had an 80% decrease in 30 days and then after 30 days, there was no difference. Cat scratch disease is a diagnosis that should be considered in patients with regional lymphadenopathy and a history of kitten or cat exposure, but the natural history is resolution of this disease without antibiotics.

Kawasaki ’s disease was first described in 1967 in Japan by Tomisaku Kawasaki. He wrote up this series of 50 children that he had treated in the six years prior and termed this mucocutaneous lymph node syndrome. Melish, in Hawaii, was the first to report this in United States’ literature, and prior to Kawasaki’s report, this disease was probably only recognized postmortem by pathologists who would term it infantile periarteritis nodosa. Kawasaki’s is an acute, self-limited illness of young children, typically characterized by prolonged fever, mucosal inflammation, skin changes, cervical lymphadenopathy and a systemic vasculitis, with a predilection for the coronary arteries. This disease occurs worldwide, but is much more common in Japan and has now replaced rheumatic fever as the most common cause of pediatric-acquired heart disease. The incidence is 10 in 100,000 in U.S. non-Asian populations, but this is tenfold higher in Japan. This disease is almost exclusively seen in younger kids. Eighty percent are less than four and the peak age is one year. Adult and adolescent cases are much rarer.

The etiology of this disease remains unknown. Most hypothesize an infectious origin because this disease is self-limited, is nonrecurring, and there are community outbreaks, one of which occurred in Harris County. This was written up by Raunch et al in 1988. They described 61 cases that they treated over three years, but there were seven over a one-month period. They did a case control study and found that all of these patients resided close to a bayou or drainage ditch, which was perhaps a reservoir for the infectious agent. The same article described similar findings seen in eastern North Carolina. Kawasaki's is rare in very young infants, so perhaps there is maternal antibody protection. Studies have shown negative cultures and serologies. Since there is no etiologic agent, it is certainly difficult to come up with a diagnostic test.

The diagnosis is based on six criteria. The first is a high spiking fever. This begins abruptly. It can be as high as 104 ° and usually lasts about one to two weeks without treatment. The next finding is a bilateral conjunctivitis, which is nonexudative. It is painless and usually occurs after the onset of fever. There are changes in the lips and oral cavity associated with erythema, dryness, and fissuring. The patients can also have a strawberry tongue. The rash is a diffuse maculopapular rash. There are no vesicles or blisters and it typically involves the trunk and extremities. There is some erythema of the extremities that evolves to a nonpitting edema to the point where young children will refuse to hold objects or even walk. As the edema resolves, children develop a periungual desquamation. Cervical lymphadenopathy is seen in about 50%-75% of patients, but interestingly, it is paradoxically prominent. It is not a subtle finding, although the other features are seen in 90% of cases. This lymphadenopathy is not fluctuant. This have been studies in the otolaryngology literature. April et al, in 1989, reviewed 83 patients over a three-year time period. Half of their patients had cervical lymphadenopathy. Interestingly, 42% of them were initially treated for unilateral bacterial adenitis. A third of them developed a rash from the antibiotic and the antibiotic was switched. Kawasaki’s disease was only considered after a lack of response to antibiotics. This is a rare disease that should be considered in a patient with cervical adenitis that does not respond to antibiotics and there is no other alternate diagnosis.

These patients have a leukocytosis with a left shift, and a normal white count can virtually eliminate this diagnosis. These patients have an elevated sedimentation rate and will develop a marked thrombocytosis, which can be greater than a million. They have a negative ANA and rheumatoid factor. Coronary artery aneurysms develop in 20% of untreated patients and can be initially detected at ten days but peaks at four weeks. Fifty percent of these aneurysms will resolve, but there are still persistent vessel wall abnormalities. These patients can have other cardiac manifestations as well. About half will develop a myocarditis, which is associated with tachycardia, which is extensive for the temperature elevation. One quarter will develop a pericardial effusion, and they can have a vasculitis of other noncoronary, medium sized arteries, although the exact incidence of that is unknown.

The diagnosis is made with five of six diagnostics signs, or four of six with evidence of coronary artery aneurysms. Therapy revolves around reducing inflammation and then prevention of coronary artery thrombosis by inhibiting platelet aggregation. The mainstay of treatment is one single high dose of IV Ig within ten days of onset, as well as aspirin, which will be high dose initially at 80mg to 100 mg per kg per day, until the fever resolves, followed by a lower dose for antiplatelet effects. Those that develop coronary artery aneurysms should be on aspirin indefinitely because of the wall abnormalities. Studies have shown that aspirin and IV Ig do decrease the aneurysm incidence to 4%, down from 20% for those treated with aspirin alone.

Case Presentation:

D.C. is a 17-year-old female who presented to Texas Children’s Hospital on July 31, 1999, with a five-day history of left neck pain and swelling. Three days prior to admission she saw her primary physician where she had a negative rapid strep test and a positive monospot test. She subsequently developed throat pain and odynophagia. She reports subjective fevers and fatigue. She was recently in Brazil for two months. She is currently on isoniazid therapy for a positive PPD nine months ago. She has not had any ill contacts. She has not had any cat contacts. She has no recent antibiotic therapy.

Past medical and past surgical history are unremarkable. Her medications include isoniazid and ibuprofen. She has no know drug allergies, and her immunizations are up to date.

On physical examination, she was in no acute distress. Temperature was 101. Tympanic membranes were clear and intact bilaterally. Nose is clear. Oral cavity examination reveals minimal erythema of the tonsillar pillars and the uvula is midline. Neck examination reveals large palpable tender left-sided lymphadenopathy approximately 5cm in diameter. There is minimal overlying skin erythema without any fluctuance.

Laboratory values are significant for a WBC of 21 with 82% neutrophils.

Lateral neck X-ray revealed no signs of a retropharyngeal abscess or airway compromise.

She was admitted to the pediatric service for IV antibiotics and hydration with a presumed diagnosis of mononucleosis with secondary bacterial lymphadenitis. She was initially treated with nafcillin, which was switched to clindamycin and cefotaxime, and her lymphadenitis slowly improved. Repeat monospot test and EBV titers were also negative. She continued to have spiking fevers to 104 despite antibiotic therapy. CT of the neck revealed left side adenopathy without any evidence of suppuration. She subsequently developed a rash, which was attributed to the cefotaxime and bilateral non-exudative conjunctivitis. Additional laboratory evaluation revealed a persistent leukocytosis with elevated platelets (560K) and ESR (110). The remainder of her serologic work-up was negative. Echocardiogram was ordered on hospital day ten, which ultimately revealed a saccular aneurysm of the left main coronary artery. She was diagnosed with atypical Kawasaki's disease and received a single dose of IV Ig (2mg/kg) and high dose aspirin and defervesced promptly. She was discharged home on high dose aspirin on hospital day thirteen.

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