Cervical Adenitis

Practical Guide for Pediatrics

Definition and Generalities

Cervical lymphadenitis is inflammation of one or more lymph nodes in the neck. It is one of the most frequent consultations in pediatric practice and, although most cases are benign and self-limiting, its differential diagnosis is broad and requires a systematic approach.

Key Points

  • It generally presents as a unilateral increase in volume in the neck.
  • The most frequent location is submandibular and anterior cervical.
  • Most cases are of infectious origin (viral or bacterial).
  • The main challenge is to differentiate benign causes from serious pathologies.

Common Etiology

The causes vary depending on age and clinical presentation (acute vs. subacute/chronic). Upper respiratory tract viral infections are the most common cause of bilateral reactive lymphadenopathy.

Unilateral Acute Adenitis

  • Bacterial:
    • Staphylococcus aureus (most common)
    • Streptococcus pyogenes (Group A)
    • Anaerobes (associated with dental infections)
  • Viral:
    • Adenovirus
    • Epstein-Barr virus (EBV)
    • Cytomegalovirus (CMV)

Subacute/Chronic Adenitis

  • Nontuberculous mycobacteria (NTM): Typically unilateral, painless, with purplish skin.
  • Cat scratch disease: Bartonella henselae.
  • Toxoplasmosis: Toxoplasma gondii.
  • Tuberculosis: Mycobacterium tuberculosis.

Systematic Clinical Evaluation

A detailed history and complete physical examination are essential to guide the diagnosis.

Key Anamnesis

  • Evolution time: Acute (< 2 weeks), subacute (2-6 weeks), chronic (> 6 weeks).
  • Associated symptoms: Fever, odynophagia, respiratory symptoms, skin rash.
  • Exhibitions: Contact with cats (Bartonella), consumption of raw meat/unpasteurized milk (Toxoplasma, Brucella), recent travel, contact with TB.
  • B Symptoms (Red Flags): Persistent fever, weight loss, night sweats.

Physical examination

Evaluate the 7 "S" of lymph nodes:

Size: >2 cm is more suspicious.
Site (Location): Supraclavicular is highly abnormal.
Symptoms (Local Symptoms): Pain, erythema, heat (suggests bacterial infection).
Soft/Hard (Consistency): Hard/stony are worrying. Gummy in lymphoma.
Suppuration: Abscess.
Stuck-down: Fixed to deep planes suggests malignancy.
Systemic: Hepatosplenomegaly, generalized lymphadenopathy.

Management Algorithm

A structured approach is key to efficient management. Click the button to see the decision flowchart.

Diagnostic Studies

Most cases do not require studies. They are reserved for atypical, serious cases or those that do not respond to treatment.

  • Blood Analysis

    Hemogram, ESR and CRP. Useful to differentiate viral (lymphocytosis) from bacterial (neutrophilia, elevated CRP/ESR). Serologies (EBV, CMV, Bartonella, Toxoplasma) as suspected.

  • Doppler ultrasound

    It is the imaging studio of choice. Allows:

    • Confirm the lymph node nature of the mass.
    • Differentiate between reactive and suppurative adenitis (abscess).
    • Evaluate suspicious characteristics (loss of fatty hilum, rounded shape, abnormal vascularization).
    • Guide fine needle aspiration (FNAC).

  • PPD or IGRA

    Indicated if there is suspicion of tuberculosis or NTM, especially in chronic adenitis and with epidemiological risk factors.

  • Biopsy (FNAC or Excisional)

    Reserved for:

    • Suspected malignancy (supraclavicular nodes, hard, adhered, B symptoms).
    • Absence of diagnosis after initial studies.
    • Lack of response to adequate treatment.

Final Evaluation

1. What is the most common bacterial etiological agent in unilateral acute cervical adenitis in children?

2. What is the first-line imaging study to evaluate cervical adenitis?

3. The presence of lymphadenopathy in the supraclavicular region should primarily raise the suspicion of:

4. A child with submandibular lymphadenopathy of 4 weeks' duration, painless and with purplish skin above, what is the most likely diagnostic suspicion?

5. What is the first-line empirical antibiotic treatment for uncomplicated bacterial adenitis?

Literature

  • Leung AK, Robson WL. Childhood cervical lymphadenopathy. J Pediatr Health Care. 2004 Jan-Feb;18(1):3-7.
  • Nield LS, Kamat D. Lymphadenopathy in children: when and how to evaluate. Clin Pediatr (Phila). 2004 Jan-Feb;43(1):25-33.
  • Deosthali A, Liewehr S, Ricalde P. Cervical lymphadenopathy. Otolaryngol Clin North Am. 2018 Dec;51(6):1155-1165.
  • Kelly CS, Kelly RE Jr. Lymphadenopathy in children. Pediatr Clin North Am. 1998 Aug;45(4):875-88.
  • Section on Infectious Diseases, American Academy of Pediatrics. Red Book: 2021–2024 Report of the Committee on Infectious Diseases. 32nd ed. Itasca, IL: American Academy of Pediatrics; 2021.