Our step-wise approach to the evaluation and initial management of axillary lymphadenopathy in children

1. History and examination to look for obvious causes or worrisome features*

2. Refer children with worrisome features for early biopsy^¶

3. Evaluate and treat causes that appear obvious based on initial evaluation

4. When the cause remains uncertain after the initial evaluation:

Lymph node ≥2 cm (0.8 inches) in longest diameter:

a. Obtain CBC/differential, ESR/CRP, LDH, CXR

Worrisome features*: Proceed to biopsy^¶
No worrisome features*:
- Signs of infection in lymph node or distal to lymph node:
  - Obtain cultures and other microbiologic studies as indicated^Δ
  - Provide 10 to 14 day trial of antibiotic therapy, broadened as indicated^◊
- No signs of infection:
  - Observe for two to three weeks

b. Response to antibiotic therapy/broadened antibiotic therapy^Δ or observation

Regression in size: No additional evaluation or therapy
No regression or increase: Biopsy^¶

Lymph node <2 cm (0.8 inches) in longest diameter:

a. Initial management according to symptoms/signs of infection within or distal to node:

Symptoms or signs of infection:
- Obtain cultures and other microbiologic studies as indicated^Δ
- Initiate a 10 to 14 day trial of antibiotic therapy, broadened as indicated^◊
No symptoms or signs of infection:
- Observe for two to three weeks

b. Response to antibiotic therapy/broadened antibiotic therapy^◊ or observation:

Regression in size: No additional evaluation or therapy
No regression or increase: Obtain a CBC/differential, perform TST, and initiate or broaden antimicrobial therapy
- CBC/differential concerning for malignancy (eg, lymphoblasts, cytopenias in more than one cell line): Biopsy^¶
- TST positive: Additional evaluation as indicated for tuberculosis or nontuberculous mycobacteria
- TST negative and lymphadenopathy regresses in size: No additional evaluation or therapy
- TST negative and lymphadenopathy does not regress in size: Obtain ESR/CRP and serology for EBV, CMV, HIV, and Bartonella henselae (for children with exposure to cats or kittens); evaluate other conditions as indicated by the history and examination^Δ

5. Obtain biopsy^¶ after four weeks if the diagnosis remains uncertain and the lymph node has not regressed in size or there is no response to antimicrobial therapy/broadened antimicrobial therapy

CBC: complete blood count; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; LDH: lactate dehydrogenase; CXR: chest radiograph; TST: tuberculin skin test; EBV: Epstein-Barr virus; CMV: cytomegalovirus; CA-MRSA: community-associated methicillin-resistant Staphylococcus aureus.
* Worrisome features include systemic symptoms (fever >1 week, night sweats, weight loss [>10% of body weight]); fixed nontender nodes in the absence of other symptoms; abnormal chest radiograph (eg, mediastinal mass or hilar adenopathy); abnormal CBC/differential; lack of upper respiratory tract symptoms; lymph nodes >2 cm in diameter that have increased in size from baseline or have not responded to two weeks of antibiotic therapy; and persistently elevated ESR/CRP or rising ESR/CRP despite antibiotic therapy. Refer to UpToDate topic on evaluation of peripheral lymphadenopathy in children for details.
¶ Excisional biopsy is preferred; fine needle aspirate biopsies usually are inadequate for evaluation of pediatric malignancies or infiltrative diseases.
Δ Refer to UpToDate topic on evaluation of peripheral lymphadenopathy in children for details.
◊ Empiric antibiotic therapy should include coverage for common pathogens such as group A Streptococcus and S. aureus (eg, clindamycin in areas with a high prevalence of CA-MRSA or a first-generation cephalosporin [eg, cephalexin] or amoxicillin-clavulanate in areas with a low prevalence of CA-MRSA). If the patient's systemic symptoms (eg, fever) do not improve within 72 hours or the lymph node increases in size (at any point during treatment), we broaden the antimicrobial coverage to include coverage for common pathogens that were not included initially (eg, CA-MRSA, B. henselae [for children with exposure to cats or kittens]). Refer to UpToDate topic on evaluation of peripheral lymphadenopathy in children for details.

Graphic 106346 Version 5.0

خرید پکیج

Our step-wise approach to the evaluation and initial management of axillary lymphadenopathy in children