Lymphadenitis Clinical Presentation

The history in patients with lymphadenitis may include the following:

• Upper respiratory symptoms, sore throat, earache, coryza, conjunctivitis, and impetigo
• Fever, irritability, and anorexia
• Contact with animals, especially kittens

Dental care

Submaxillary adenopathy may develop secondary to stomatitis, dental caries, or a dental abscess.

Risk factors for tuberculosis ^[3]

Generalized lymphadenopathy in a child with tuberculosis may indicate a hematogenous spread of tubercle bacilli.

Localized involvement is most common in the mediastinal, mesenteric, or anterior cervical nodes.

Acute or chronic onset

Usually, bilateral acute cervical adenitis is caused by either viral pharyngitis or infectious mononucleosis.

Chronic localized adenopathy can be attributed to a persistent regional infection.

Skin and scalp conditions

Occipital and postauricular adenopathy may accompany scalp infections, seborrheic dermatitis, or scalp pediculosis. Epitrochlear and axillary lymphadenopathy may result from infections on the arms. Inguinal and femoral adenopathy may be due to infections on the lower extremities.

Periodicity

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome usually results in adenopathy associated with the other findings every 3-6 weeks.

History of travel

When adenopathy is caused by Yersinia pestis (bubonic plague), the patient may have visited a rural area in the western United States one week prior to the onset of illness.

Medication use

The following medications may have been used:

• Hydantoin
• Mesantoin

Age

Atypical mycobacteria typically cause adenopathy in toddlers.

Physical findings may include the following:

Location

Tularemia may be accompanied by regional adenopathy, most commonly cervical.

Yersinia enterocolitica infection may cause cervical or abdominal adenopathy.

Salmonella infections may accompany generalized lymphadenopathy.

Rubella and parvovirus infection is characterized by enlarged and tender posterior auricular, posterior cervical, and occipital lymph nodes.

Atypical (environmental) mycobacteria may cause submandibular or submental adenopathy.

Mediastinal or infectious hilar adenopathy may occur in patients with tuberculosis, chronic sinusitis, histoplasmosis, tularemia, infectious mononucleosis, candidiasis, coccidioidomycosis, and bronchiectasis.

Size

Lymph nodes that are noted to increase rapidly in size may indicate potential malignancy.

Shape

Confluent lymph nodes may be indicators of malignancy.

Consistency

Descriptors may include soft, fluctuant, firm, rubbery, or hard.

In early stages, nodes in tuberculosis are well-demarcated, mobile, nontender, and firm. If the infection remains untreated, the nodes soften, become fluctuant, and adhere to the skin, which may be erythematous.

In Hodgkin disease, nodes are initially soft. They later become firm and rubbery.

Fixation of lymph nodes to the skin and soft tissue may indicate malignancy.

Tenderness

Lymph nodes of infectious etiology are usually tender.

Bubonic plague, caused by Y pestis, may cause extremely tender lymph node enlargement and erythema of overlying skin in the inguinal, femoral, axillary, or cervical area.

Hodgkin lymphoma may initially present as painless lymph node enlargement, especially of the cervical and supraclavicular region.

Overlying skin

The overlying skin may be erythematous in infectious etiologies.

Draining sinuses may develop in patients with tuberculous adenopathy.

Infants with atopic eczema may have generalized lymphadenopathy.

Systemic signs

Group B streptococcal cellulitis and adenitis, which may occur in infants younger than 2 months, are characterized by sudden onset of fever, anorexia, irritability, and submandibular swelling. Usually, a blood culture test demonstrates positive results.

Hepatosplenomegaly is common in patients with infectious mononucleosis.

Conjunctivitis

Preauricular adenopathy (Parinaud oculoglandular syndrome) secondary to uniocular granulomatous conjunctivitis may be caused by catscratch disease, chlamydial conjunctivitis, listeriosis, tularemia, or tuberculosis.

Adenovirus type 3 causes pharyngeal conjunctival fever. Symptoms associated with adenovirus type 3 include follicular conjunctivitis with enlarged preauricular and/or posterior cervical nodes. Adenovirus type 8 causes epidemic keratoconjunctivitis, which causes preauricular adenopathy.

PFAPA syndrome

Aphthous stomatitis and pharyngitis are associated with PFAPA syndrome.

Number

A single node or multiple nodes may be involved.

Catscratch disease

In catscratch disease, usually only a single node is involved.

Causes of lymphadenitis include the following:

Infections

Acute, one-sided, pyogenic adenitis is most common. The involved node may be firm and tender, with erythema of the overlying skin. Etiologic agents include group A beta-hemolytic streptococci, staphylococcal organisms (especially Staphylococcus aureus),^[4] and viruses.

Tularemia may be accompanied by regional adenopathy, most commonly cervical, with local tenderness, pain, and fever. Generalized lymphadenopathy may also develop.^[5]

In a child with tuberculosis, generalized lymphadenopathy may indicate hematogenous spread of tubercle bacilli. Localized involvement is most common in the mediastinal, mesenteric, or anterior cervical nodes. Initially, the nodes are discrete, firm, mobile, and tender. If the patient remains untreated, the nodes soften, become fluctuant and matted, and adhere to overlying skin, which may become erythematous. Bilateral involvement is characteristic of this condition. Pulmonary disease is common.

Atypical mycobacteria can manifest cervical or submandibular involvement identical to that of tuberculosis, except the involvement is usually unilateral.^[6]

Group B streptococcal cellulitis and adenitis may occur in infants younger than 2 months.

Brucellosis may accompany chronic or intermittent lymphadenopathy.

Y enterocolitica may be associated with cervical lymphadenitis.

Salmonella infection can correspond to generalized adenopathy.

Bubonic plague is caused by Y pestis.

In patients with catscratch disease, the site of the scratch determines if axillary, epitrochlear, supraclavicular, femoral, inguinal, or submaxillary lymph nodes are involved. The nodes are nontender, discrete, mobile, and moderately or greatly enlarged. Occasionally, tenderness, redness, warmth, and suppuration may occur. Bartonella henselae is the organism that causes catscratch disease.

Patients with infectious mononucleosis typically present with discrete, firm, nontender lymph nodes. Usually, anterior cervical nodes are involved. Generalized lymphadenopathy may occur, and hepatosplenomegaly is common.

Cytomegalovirus or toxoplasmosis may cause a mononucleosislike syndrome with generalized adenopathy, fever, atypical lymphocytes, and hepatosplenomegaly.

Gianotti-Crosti syndrome accompanies generalized lymphadenopathy, hepatomegaly, splenomegaly, nonicteric hepatitis, and crops of papular lesions that persist for 2-8 weeks.

Immunologic or connective tissue disorders

Juvenile rheumatoid arthritis should be considered in unexplained fever and persistent lymphadenopathy in a child.

Serum sickness can correspond with generalized tender lymphadenopathy.

Chronic graft versus host disease may occur.

Primary disease of lymphoid or reticuloendothelial tissue

These include the following:

• Acute leukemia
• Lymphosarcoma
• Reticulum cell sarcoma
• Hodgkin disease
• Non-Hodgkin lymphoma
• Malignant histocytosis or histocytic lymphoma
• Nonendemic Burkitt tumor
• Nasopharyngeal rhabdomyosarcoma
• Neuroblastoma^[7]
• Thyroid carcinoma, chronic lymphocytic thyroiditis
• Histiocytosis X
• Kikuchi disease^[8]
• Benign sinus histiocytosis
• Angioimmunoblastic or immunoblastic lymphadenopathy
• Chronic pseudolymphomatous lymphadenopathy (chronic benign lymphadenopathy)

Immunodeficiency syndromes and phagocytic dysfunction

These include the following:

• Chronic granulomatous disease of childhood
• Acquired immunodeficiency syndrome
• Hyperimmunoglobulin E (Job) syndrome

Metabolic and storage diseases

These include the following:

• Gaucher disease
• Niemann-Pick disease
• Histiocytosis X
• Cystinosis

Hematopoietic diseases

These include the following:

• Sickle cell anemia
• Thalassemia
• Congenital hemolytic anemia
• Autoimmune hemolytic anemia

Other disorders

Kawasaki disease usually presents with cervical adenopathy that is unilateral and with nodes that are firm, nontender, and greater than 1.5 cm in diameter.^[9] Overlying skin may be erythematous but not warm.^[10]

PFAPA syndrome usually occurs in young children (onset almost always before age 5 y) and is remarkable because of its regular periodicity. All findings may not occur in each patient. Children are otherwise healthy between episodes and display normal growth and development. During the acute episodes, elevation of inflammatory markers (eg, WBC count, erythrocyte sedimentation rate) is often present. A recent study determined that the Gaslini diagnostic score is a useful tool in differentiating PFAPA syndrome from monogenic periodic fevers.^[11]

Drug use can affect lymph nodes. Mesantoin use may cause enlargement of lymph nodes (most commonly in the cervical region), fever, eosinophilia, rash, and hepatosplenomegaly. Hydantoin use also may produce lymphadenopathy as an adverse effect.

Almost all patients with sarcoidosis demonstrate either generalized or hilar lymphadenopathy. When enlarged, bilateral cervical nodes are firm, rubbery, and discrete, with little tendency to coalesce. Other symptoms include fatigue, cough, fever, dyspnea, and weight loss. Hyperglobulinemia and eosinophilia are common laboratory findings.

Castleman disease or benign giant lymph node hyperplasia may cause lymphadenopathy in the mediastinum, abdomen, neck, or axilla. Some patients experience fever, anemia, weight loss, and hyperglobulinemia.