Pediatric Primary Care (54 page)

2.  Negative serology for other causes of adenopathy, sterile pus aspirated from a node, a positive PCR assay, and/or liver/spleen lesions seen on CT scan.

3.  Positive enzyme immunoassay or IFA with a titer ratio of > 1:64.

4.  Biopsy showing granulomatous inflammation consistent with CSD or positive Warthin-Starry silver stain.

F.  Differential diagnosis.

1.  Other causes of lymphadenopathy.

a.  Common viral and bacterial infections such as Group A betahemolytic streptococci (GABHS), staphylococci, cytomegalovirus (CMV), Epstein-Barr virus (EBV; infectious mono), HIV.

2.  Subacute and chronic lymphadenopathy more likely associated with mycobacterium and toxoplasmosis.

3.  Neck masses from other sources.

G.  Treatment.

1.  Symptomatic.

a.  Antipyretics and analgesics.

b.  Moist wraps/compresses.

c.  Aspiration of painful nodes (avoid I&D).

d.  Antimicrobial treatment for severely ill patients or those with other chronic condition. Not suggested for regional CSD.

e.  For patients with significant lymphadenopathy: Azithromycin (Zithromax): 500 mg day 1, 250 mg days 2-5; younger children 10 mg/kg day 1, 5 mg/kg days 2-5.

f.  Other antibiotics with anecdotal evidence of efficacy: ciprofloxacin, rifampin, trimethoprim-sulfamethoxazole.

H.  Follow up.

1.  Every week until resolution of symptoms, dependent on severity of symptoms.

I.  Complications.

1.  Parinaud oculoglandular syndrome: inoculation of conjunctiva results in ipsilateral preauricular or submandibular lymphadenopathy.

2.  Less commonly: encephalitis, aseptic meningitis, neuroretinitis, thrombocytopenia purpura, erythema nodosum, pneumonia, hepatosplenomegaly, osteomyelitis, endocarditis.

J.  Education.

1.  Avoid scratches by decreasing rough play with kittens.

2.  Immediately cleanse wounds from cats.

IV. CERVICAL LYMPHADENITIS

A.  Etiology.

1.  Enlargement of lymph glands of neck generally due to:

a.  Infection, which causes proliferation and invasion of inflammatory cells.

•  Viruses:

i.  Upper respiratory: respiratory syncytial virus (RSV), adenoviruses, influenza, parainfluenza, rhinoviruses–which usually resolve more quickly than other etiologies.

ii.  EBV.

iii. CMV–rare.

iv.  Rubella, rubeola, roseola–rare.

v.  Varicella zoster–rare.

vi.  HSV.

vii.  Coxsackie.

viii. HIV–rare.

•  Bacteria:

i.  
Staphylococcus aureus
and GABS: 40-80% of cases.

ii.  Anaerobes–rare.

iii. Corynebacterium diphtheriae.

iv. 
Bartonella henselae
(cat-scratch disease).

v.  Gram-negative rods:
Haemophilus influenzae
, pseudomonas, salmonellae, shigellae,
Francisella tularensis
(tularemia).

•  Mycobacterium.

i.  Mycobacterium tuberculosis.

ii.  Nontuberculous mycobacteria (NTM).

•  Spirochetes.

•  Rickettsiae.

•  Fungi, including
Histoplasma capsulatum
(histoplasmosis)–rare.

•  Protozoa, including
Toxoplasma gondii
(toxoplasmosis)–rare.

b.  Other causes.

•  Neoplasms that cause infiltration of neoplastic cells–rare.

•  Histiocytosis.

•  Collagen vascular diseases: juvenile rheumatoid arthritis (JRA), lupus.

•  Sarcoidosis.

•  Kawasaki disease.

•  Postvaccination: DTaP, polio, typhoid.

•  Drugs-phenytoin, INH.

B.  Occurrence.

1.  About 40% of all children have palpable cervical lymph nodes.

2.  Most cases of cervical lymphadenitis resulting from common bacterial and viral infections occur in toddler and preschool age groups.

3.  Etiologic and age-related occurrence.

a.  Neonate.

•  Acute unilateral cervical lymphadenitis:
S. aureus.

•  “Cellulitis-adenitis” syndrome: late-onset Group B streptococcus.

b.  Younger than 5 years of age.

•  Acute pyogenic cervical lymphadenitis:
S. aureus
and GABHS.

•  NTM lymph node infection.

•  Kawasaki disease (also usually unilateral).

c.  School-aged and adolescents: more likely chronic cervical lymphadenitis than acute pyogenic disease.

C.  Clinical manifestations.

1.  Acute bilateral cervical lymphadenopathy generally caused by URI or strep pharyngitis. Generally associated with EBV (infectious mononucleosis).

2.  Acute unilateral cervical lymphadenitis variably associated with fever and suppuration, most often caused by staph and Group A streptococcus.

3.  Subacute and chronic lymphadenitis are found in cat-scratch disease, toxoplasmosis, and mycobacterial infections. Nodes become fluctuant and are generally nontender.

4.  Painless, possibly matted nodes and especially those in supraclavicular area are more likely malignant.

5.  Associated symptoms.

a.  With URI: fever, sore throat, cough.