Lymphadenopathy

Question 1

List the differential diagnosis for cervical lymphadenopathy

Answer 1

• Differential diagnosis
  
  • ​normal- small, discrete, pea-sized, mobile nodes
  • viral/ bacterial- small, multiple nodes in neck
    
    • Mycobacterium avium complex - Adenoapthy is usually unilateral and most cases occur in the under 5-year age group. Non-tender, slightly fluctuant node, which may become tethered to underlying structures. Violaceous hue to the overlying skin is sometimes seen. Systemically well. Usually not immunocompromised.

Mycobacterium tuberculosis - non-tender nodes. History of exposure. Systemic symptoms of fever, malaise, weight loss.

Cat Scratch Disease (Bartonella henselae) - tender, usually axillary, nodes. History of a cat scratch or lick 2 weeks prior. There may be a papule at the site.

Toxoplasma gondii - generalised lymphadenopathy. Systemic features of fatigue or myalgia.

HIV

Malignancy

Lymphoma - Hodgkins, Non-Hodgkins

Leukaemia - ALL, AML, CML,

Rheumatologic conditions

Juvenile chronic arthritis

SLE

* *extensive atopic eczema-* multiple lymph nodes of variable size, posterior neck
* *malignancy-* usually non-tender, variable size and shape
* *infected node/ abscess-* anterior neck. Large, hot, sometimes fluctuant. Group A strep/ strep pyogenese/ S. aureus = common causes. \> 10mm.
* Kawasaki disease- unilateral, \> 15mm/ cat scratch- variable size and shape

Question 2

Initial investigations for cervical lymphadenopathy

Answer 2

• Persisting adenitis (>2 weeks) - consider the following

FBE/film

Serology - EBV, CMV, HIV, Toxoplasmosis, Cat scratch

Mantoux test

CXR

CT may be required preoperatively

Excision biopsy

Question 3

List the common causes. investigations and Ddx (incl. biopsy) for lymphadenitis

Answer 3

Fluctuant Node Incision and drainage (contraindicated in suspected TB as may result in sinus formation)

Well - oral antibiotics for 10 days, with review in 48 hours.

Flucloxacillin 25 mg/kg QID

Hypersensitivity to penicillin: Cephalexin 25 mg/kg (up to 500mg) TDS
Severe penicillin hypersensitivity: Erythromycin 15 mg/kg (up to 500mg) TDS

Neonates, unwell or failed oral Rx - IV antibiotics

Flucloxacillin 50 mg/kg up to 2 g 6-hourly

Hypersensitive to penicillin: Cephazolin 25 mg/kg up to 2g IV 6 hourly
Severe penicillin hypersensitivity: Clindamycin 10mg/kg up to 450mg 6hourly

Investigations

No blood investigations

MCS if incision and drainage