Our step-wise approach to the evaluation and initial management of inguinal 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 and tender:
- Initiate 10 to 14 day trial of antibiotic therapy, broadened as indicated^Δ
  - Regression in size: No additional evaluation or therapy
  - No regression in size: Obtain CBC/differential, ESR/CRP, CXR, TST, Bartonella henselae serology and provide referral or treatment based on the results
Lymph node ≥2 cm (0.8 inches) in longest diameter, nontender, with symptoms/signs of infection within or distal to node
- Obtain bacterial and fungal cultures or other fungal studies as indicated by the initial evaluation^◊, B. henselae serology, and provide a 10 to 14 day trial of antibiotic therapy, broadened as indicated^Δ
  - Regression in size: No additional evaluation or therapy
  - No regression in size: Obtain CBC, ESR/CRP, and CXR to evaluate worrisome features*
Lymph node ≥2 cm (0.8 inches) in longest diameter, nontender, no symptoms/signs of infection within or distal to node
- Obtain CBC/differential, ESR/CRP, LDH, CXR and abdominal ultrasonography
  - Worrisome features*, abdominal mass, or abdominal lymphadenopathy: Proceed to biopsy^¶
  - No worrisome features*, no abdominal mass or lymphadenopathy, and cause remains uncertain: Perform TST and provide a 10 to 14 day trial of antibiotic therapy broadened as indicated^Δ
    - TST positive: Additional testing may be necessary to establish diagnosis of tuberculosis or NTM
    - TST negative and lymph node regresses in size: No additional evaluation or therapy
    - TST negative, lymph node does not regress: Obtain additional microbiologic studies as indicated by the history and examination^◊ and provide referral or treatment based on the results
Lymph node <2 cm (0.8 inches) in longest diameter:
- Worrisome features*: Proceed to biopsy^¶
- No worrisome features*: Continue to observe, even if the lymph node does not regress after four weeks

5. For lymph nodes ≥2 cm (0.8 inches), 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; CXR: chest radiograph; TST: tuberculin skin test; LDH: lactate dehydrogenase; NTM: nontuberculous mycobacteria; 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.
¶ Excisional biopsy is preferred; fine needle aspirate biopsies usually are inadequate for evaluation of pediatric malignancies or infiltrative diseases.
Δ 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). Refer to UpToDate topic on diagnostic approach to peripheral lymphadenopathy in children for details.
◊ Refer to UpToDate topic on evaluation of peripheral lymphadenopathy in children for details.

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