Pediatric emergency medicine trisk 0952 0952
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appearing patients, admission and treatment with intravenous (IV) antibiotics are
appropriate.
Cervical lymphadenitis may also be caused by viral infections including
rhinovirus, parainfluenza virus, RSV, Cytomegalovirus, and EBV. In addition to
prominent posterior cervical nodes, EBV classically presents with a
mononucleosis-like illness including fever, headache, malaise, and tonsillar
hypertrophy. Diffuse lymphadenopathy and the presence of hepatosplenomegaly
are also frequently present. Treatment for mononucleosis is generally supportive.
Exudative pharyngitis warrants evaluation for concurrent GAS, and should be
treated with antibiotics if positive. Corticosteroids (prednisolone/prednisone at 1
mg/kg/day often prescribed as a short burst and then a taper) may be useful in
patients with airway obstruction.
Cat-scratch disease also causes regional lymph node enlargement in children,
typically presenting 2 to 4 weeks after a cat or kitten scratch. Scratches to the
head and neck result in cervical lymph node enlargement in 33% to 50% of those
affected. Fever and malaise precede the development of a single, enlarged node in
30%. This is followed by local erythema, warmth, tenderness, and induration of
the area. Labs for Bartonella henselae (the causative agent), will be positive in
approximately 84%, and 16% of patients within 1 to 2 weeks of symptoms, and 4
to 8 weeks of symptoms, respectively. Needle aspiration has both therapeutic and
diagnostic potential. Conversely, surgical excision may create a draining sinus.
Bartonella henselae can be identified via immunofluorescent antibody assay to
both IgM and IgG antibodies. Symptomatic treatment generally results in
resolution over 2 to 4 months. Indications for antibiotic treatment include painful
adenitis, systemic symptoms (hepatic or splenic involvement, endocarditis), or
immunocompromise. Azithromycin is the first-line antibiotic choice. Rifampin,
ciprofloxacin, parenteral gentamicin, and trimethoprim-sulfamethoxazole are
moderately to highly effective in treating severe disease (hepatosplenic disease,
persistent temperature >39.5°C, or severe systemic signs). Parenteral ceftriaxone
and gentamicin, with or without oral doxycycline, are suggested for those with
culture-negative endocarditis. Bartonella-positive endocarditis is generally treated
with doxycycline and gentamicin.
Mycobacterial infection of the cervical lymph nodes can be caused by the
atypical strains of Mycobacterium avium-intracellulare (MAI), Mycobacterium
scrofulaceum, or less frequently, Mycobacterium tuberculosis (M. tb). Atypical
mycobacterial infection presents with enlarged, erythematous, “rubbery” nodes
which are generally submandibular in location, and minimally tender to palpation.
In contrast, the supraclavicular lymphadenopathy caused by M. tb is more
