Cervical Lymphadenitis

Cervical lymphadenitis is enlargement and inflammation of neck lymph nodes from infection, most often in children, with causes ranging from viral and bacterial infections to tuberculosis, non tuberculous mycobacteria, HIV, toxoplasmosis and malignancy. Acute bilateral small nodes are usually viral; acute unilateral tender nodes are usually bacterial; chronic, painless nodes need exclusion of tuberculosis and malignancy.

• Kenya has a high burden of tuberculous cervical lymphadenitis, especially in HIV.

Acute: tender, warm node with fever, sore throat or dental source. Subacute or chronic: painless, firm or matted nodes, with weight loss, fever and night sweats.

• Features of malignancy: hard, fixed, supraclavicular, rapidly enlarging, over 3 cm, no tenderness.
• Differential diagnosis: viral infection (EBV, CMV, adenovirus), streptococcal and staphylococcal lymphadenitis, tuberculosis, non tuberculous mycobacteria, cat scratch disease, toxoplasmosis, HIV, Kawasaki disease, lymphoma, leukaemia, metastatic nasopharyngeal carcinoma, Kikuchi disease, sarcoidosis, branchial cyst.
• Complications: abscess, sinus, airway compression, spread to deep neck, systemic infection, delay in diagnosing malignancy.

Stepwise approach.

• History (duration, fever, contacts, animals, ingestions) and examination of throat, teeth, scalp, skin and other node groups.
• Full blood count and film, CRP, ESR, HIV test, EBV and CMV serology, toxoplasma IgG/IgM, Bartonella serology, tuberculosis tests (Xpert MTB/RIF on aspirate, interferon gamma release assay), chest radiograph.
• Ultrasound; fine needle aspiration for cytology, culture and PCR; excision biopsy if aspirate is non diagnostic or malignancy suspected.

Treat the cause; antibiotics for acute bacterial lymphadenitis.

• Supportive: analgesia (paracetamol 1 g, 15 mg/kg), warm compress, hydration, dental care, observe viral nodes for 2 to 4 weeks.
• Pharmacological: acute bacterial: flucloxacillin 500 mg to 1 g four times daily for 7 to 10 days (children 12.5 to 25 mg/kg four times daily), amoxicillin clavulanate 625 mg three times daily if dental source, clindamycin 300 to 450 mg three times daily if allergic. Cat scratch disease: azithromycin 500 mg then 250 mg daily for 4 days. Tuberculosis: isoniazid 5 mg/kg, rifampicin 10 mg/kg, pyrazinamide 25 mg/kg and ethambutol 15 mg/kg daily for 2 months then isoniazid and rifampicin for 4 months, with pyridoxine 25 mg daily. Toxoplasmosis in immunocompetent adults: observation.
• Procedures: needle aspiration of fluctuant nodes; excision biopsy; surgical excision of non tuberculous mycobacterial nodes.
• Special groups: pregnancy, flucloxacillin, and the four drug tuberculosis regimen with pyridoxine; children, weight based doses and tuberculosis contact tracing; HIV, aggressive search for tuberculosis and lymphoma.
• Red flags: hard fixed nodes, supraclavicular nodes, night sweats and weight loss, node over 3 cm persisting beyond 4 weeks, stridor, bleeding.
• Follow-up: review at 2 weeks; biopsy if not shrinking at 4 to 6 weeks; ENT review for nasopharyngeal examination in adults.