History
In most situations, performing a thorough history, a review of symptoms, and a physical examination can establish the likely etiology of the lymphadenopathy and render any further tests unnecessary.
Evaluation of the child with lymphadenopathy may begin with specific aspects of the enlarged lymph node or nodes and then expand to encompass the various aspects that may have caused it. The duration of lymph node enlargement often guides therapy. In general, benign lymphadenopathy resolves over 4-6 weeks, whereas persistent or progressive lymphadenopathy raises the possibility of malignancy.
In addition to duration, the clinician must evaluate for any associated symptoms. Other general questions include recent or past illnesses, infections, local trauma, or bites. Exposure to drugs and specifically antibiotics is also important because it may shrink the lymph nodes. If no obvious sources of infection are present, the presence of constitutional symptoms such as fever, weight loss, and night sweats are potential signs of malignancy. These are commonly referred to as B symptoms. If the patient has recurrent infections, immunodeficiencies such as HIV infection must be considered.
Information regarding family and social history is helpful to exclude associated malignancies and is useful to allay fears that cancer can run in the family. Social history may elicit potential sources of lymphadenopathy, including recent travel, drinking of unsanitized water, exposure to animals that may carry unique infections, exposure to tuberculosis (TB), exposure to typhoid, and exposure to trypanosomiasis. Information about activities such as sexual contact is also important. If the history is otherwise unremarkable, a thorough review of symptoms may establish other aspects of causation.
Physical Examination
The physical examination of a child with lymphadenopathy begins as a complete examination and then focuses on the enlarged node(s). The skin and the soft tissue drained by the enlarged node should be carefully examined for signs of inflammation, skin breakdown, and trauma. The character of the lymph node should be noted. Normal lymph nodes are described as soft, easily compressible, and freely mobile. Hyperplastic lymph nodes that develop as a response to viral infections are small, discrete, mobile, nontender, and bilateral. Usually, no accompanying cellulitis or inflammation is present.
Lymph nodes that are acutely infected with bacteria—most often S aureus or group A streptococci [6, 13] —tend to be large, warm, and tender and have surrounding erythema and edema. Infected lymph nodes may progress and develop an abscess. Chronically infected nodes tend to have discrete margins and are adherent to underlying tissues and have minimal signs of inflammation.
Nodes that are associated with malignancy tend to be larger than 2 cm, involve several groups of nodes, and occur in children older than 8 years. [14, 15] Lymphadenopathy associated with malignancy has been described as firm or rubbery, discrete, nontender, and fixed to the skin or underlying structures. [6, 15]
With a thorough physical examination, the clinician can broadly classify the lymphadenopathy as either a local or a general phenomenon. A localized lymphadenopathy usually results from abnormalities of the area in which the lymph node drains (eg, infection), though it cannot be excluded as the first sign of a precocious clinical manifestation in the course of a progressive systemic process. The appearance of a generalized lymphadenopathy suggests a systemic disease and orients the clinician more directly toward serologic and hematologic testing.
Of the regional lymphadenopathies, occipital and preauricular locations are rarely malignant; the former are often related to scalp and outer-ear infections, exanthematous diseases, and toxoplasmosis, whereas the latter are associated with infections of superficial tissue of the orbit, the middle ear, and the parotid glands. Submental lymphadenopathy requires a search for disorders in the anterior portion of the mouth and the lower lip, the submandibular portion of the face, the nose, the maxillary sinus, the mucosa of the oral cavity, the floor of the mouth, and the submental salivary gland.
Laterocervical lymphadenopathy in the upper portion of the neck can be associated with inflammatory or neoplastic disorders of the hypopharynx, the larynx, or the thyroid gland, whereas those in the lower part of the neck are related to disorders of the hypoglottic larynx, the thyroid, and the upper portion of the esophagus. Supraclavicular and epitrochlear enlargement must be considered as red flags for the potential of malignancy.
Enlarged axillary and inguinal lymph nodes are usually of benign etiology. Axillary lymphadenopathy is seen with infections of the upper extremity, chest wall, group tissue, and intrathoracic lesions. Inguinal lymphadenopathies are caused by sexually transmitted diseases of the genitalia and other infections of the perineum and pelvis.
Enlarged popliteal lymph nodes are generally associated with infections of the foot and leg. Lymphadenopathies of the mediastinum, retroperitoneum, and mesentery usually go undetected during physical examination but are sometimes suspected on the basis of compression of the surrounding structures.
The presence of general lymphadenopathy should alert the clinician to the presence of significant pathology. Any of the following common viral illnesses may produce generalized lymphadenopathy:
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Upper respiratory tract infections ( rhinovirus, adenovirus, influenzavirus, parainfluenza virus, respiratory syncytial virus)
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Epstein-Barr virus (EBV) infection
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Cytomegalovirus (CMV) infection
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Varicella-zoster virus (VZV) infection
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Herpes simplex virus (HSV) infection
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Paramyxovirus infection
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Coxsackievirus A or B infection
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Echovirus infection
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Enterovirus infection
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Human herpesvirus-6 infection
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HIV infection
Even more concerning are the hematogenous malignancies (eg, leukemia, lymphomas) and other malignancies (eg, neuroblastoma, rhabdomyosarcoma). Some rare causes of generalized lymphadenopathy include autoimmune connective tissue diseases and the use of certain drugs, particularly phenytoin and carbamazepine.
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A preoperative radiograph showing a narrowed trachea secondary to an anterior mediastinal mass.
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A CT scan showing an anterior mediastinal mass and compression of the trachea.
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A CT scan showing an anterior mediastinal mass and compression of the left mainstem bronchus.
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A lymph node biopsy is performed. Note that a marking pen has been used to outline the node before removal and that a silk suture has been used to provide traction to assist the removal.
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A lymph node after removal by means of biopsy, which was performed completely under a local anesthetic technique.
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A gross image of a node following excision. The cut surface of the node shows the typical fish-flesh appearance seen with lymphoma.
