Bacterial Cervical Lymphadenitis: Management & Diagnosis

00:00 So, we're left now with the patient who we suspect may have bacterial cervical lymphadenitis.

00:07 There are some common organisms that can cause this and then some rare organisms that can cause this. Let’s look at the common ones first. <i>Staph aureus</i>, either MRSA or <i>Staph</i> can cause a usually purulent bacterial lymphadenitis. If it’s MRSA, it may well be needed to be drained right at the outset. Group A <i>Strep</i> can also cause a very purulent lymphadenitis which can result in an abscess. Anaerobes take a little bit longer to form an abscess but they can and those are an unusual complication or cause of bacterial cervical lymphadenitis. Often, it’s a mixed infection, a bunch of bacteria just got in there and started growing. One thing that we see more commonly in kids than you might imagine is <i>Mycobacterium avium</i> complex or MAC. This is a relative of tuberculosis. It tends to cause a unilateral area that is painful and very red and very warm to the touch. We call it scrofula. Also, TB can do it too but we don’t see that so commonly. Lastly, in the US especially in children who have recently been scratched by a cat or most likely a kitten is <i>Bartonella henselae</i>, we call that cat scratch disease. Cat scratch disease can present in an enumerable number of ways including CNS disease but its most common presentation is a unilateral large lymph node that looks infected. More rarely, we talked about tuberculosis, also tularemia which is actually more commonly tick-borne than from skinning rabbits which is what you read in the textbooks. Likewise, we’re seeing outbreaks in the United States especially on the West Coast of the Bubonic plague which presents with a whole host of illnesses in a very sick patient but lymphadenitis is part of that. Okay, we have a patient we suspect it’s one of these bacteria, we’re seeing them, we want to know what test to do. The CBC unfortunately doesn’t help very much but it may identify cancer and so I do recommend getting a CBC in these patients because it will eliminate the rare cancer that’s being missed, not eliminate it but reduce its likelihood.

02:26 A blood culture rarely helps. It might grow something but most of the time it doesn’t. If you suspect <i>Bartonella</i> titers and every single child with lymphadenitis should be asked “How does your child been potentially scratched by a kitten or a cat?, you should probably get <i>Bartonella</i> titers. Those will come back for a while but it may prevent an unnecessary operation for what is otherwise presumed to say would be, for example, <i>Mycobacterium avium</i> complex. Also, other testing might be indicated if there’s a history of something particularly going on. If you, for some reason, suspect mono because the sibling had EBV 2 weeks ago, certainly you could do that testing. It is possible to do a PPD or a Mantoux test in a patient with MAC. It may become weakly positive and that may be a clue that this is MAC. If TB is suspected, certainly we should get a PPD and we may actually also get a QuantiFERON Gold because that may be the better test especially in a child who’s recently had BCG or some other vaccine that might confuse the picture.

03:36 EBV or CMV titers may be indicated in some cases where you’re not convinced what this could be and that would change your management. Okay, you’ve gotten your test, now you want to figure out exactly what is going on by imaging. The test of choice to start out with is the ultrasound. Remember, it’s a lot less radiation, it’s generally pretty harmless and you can get an early sense of whether this does likely need to be drained or whether you can start off with conservative therapy and just antibiotics. If there’s any question, we’ll generally proceed to a CT of the neck or an MRI of the neck recognizing that for MRIs for younger kids they typically need to be sedated to hold still so maybe CT is a better option. Here’s a CT of a patient who has diffuse disease of the right side of their head. Okay, so how do we choose antibiotics in these patients? Well, we’re going to empirically start off with a broad-spectrum antibiotic such as amoxicillin/clavulanic acid. That’s a great way to start. So, oral amoxiclav because these children typically are not that sick. They may not even have a fever. Then, if that isn’t doing the trick, we may admit these patients and either put them on ampicillin/sulbactam if they haven’t been compliant on their amoxicillin/clavulanic or we may decide to switch to clindamycin for fear that this might be MRSA which is a reasonably common cause of lymphadenitis in children. If the clindamycin isn’t doing the trick and we typically would give that a few more days because clindamycin is a slow-acting agent as it's bactericidal instead of bacteriostatic but if clindamycin isn’t doing the trick for MAC, we would recommend surgical excision. It’s really the only way that’s going to get better. The surgeons tell me that usually these don’t come in as a perfect lump, they sometimes just dissolve right there on the emergency room like old cheese. Alternatively for <i>Bartonella</i>, we may not operate, we may just do supportive therapy. People do tend to use azithromycin but it’s not clear that azithromycin really helps them that much but time certainly does and they gradually should improve. So that’s my summary of Cervical Lymphadenitis in Children. Thanks for your attention.