Infectious Inflammatory Disorders
Reactive Viral Lymphadenopathy
Reactive viral lymphadenopathy is the most common cause of cervical adenopathy in children. These neck masses are usually associated with symptoms of an underlying upper respiratory tract infection. The most common viral agents include adenovirus, rhinovirus, and enterovirus. These reactive lymph nodes tend to regress in 1–2 weeks.
The management of reactive viral lymphadenopathy is usually observation; however, a neck mass larger than 1 cm should be considered abnormal and warrant further investigation if it remains for more than 4–6 weeks or increases in size. If the suspected adenopathy persists, biopsies can be taken to search for other causes, such as fungal, granulomatous, or neoplastic processes.
EBV or mononucleosis can also present with lymphadenopathy, although it is usually accompanied by the enlargement of other lymphoid tissues such as the adenoids or tonsils. Patients with the EBV also have accompanying symptoms of fever and pharyngitis. Adenopathy associated with mononucleosis may last as long as 4–6 weeks. The treatment is limited to supportive management.
HIV-Associated Inflammatory Disorders
Cervical adenopathy is present in 12–45% of patients with human immunodeficiency virus (HIV). Idiopathic follicular hyperplasia is the most common cause of adenopathy in these patients, although other infectious or neoplastic etiologies must be ruled out, including Mycobacterium tuberculosis, Pneumocystis carinii, lymphoma, and Kaposi sarcoma. The treatment of cervical adenopathy in the setting of HIV disease requires treatment of the underlying HIV infection, which is beyond the scope of this chapter.
Persistent Generalized Lymphadenopathy
Persistent generalized lymphadenopathy is lymphadenopathy without an identifiable infectious or neoplastic cause; it is commonly seen in patients with HIV infection. The neck is the most common site of persistent generalized lymphadenopathy. Once the diagnosis is made, the treatment of persistent generalized lymphadenopathy secondary to HIV infection requires treatment of the underlying HIV disease.
Suppurative lymphadenopathy is most frequently caused by Staphylococcus aureus and group A B-Streptococcus. These neck masses usually develop in the submandibular or jugulodigastric region and are often accompanied by sore throat, skin lesions, and symptoms of upper respiratory tract infection. Empirical antibiotic therapy against anaerobic and gram-positive organisms is recommended as the first line of management. If this fails, either FNA or incision and drainage may be indicated.
Toxoplasmosis is caused by Toxoplasma gondii and is contracted through the consumption of poorly cooked meat or the ingestion of oocytes excreted in cat feces. Patients present with fever, malaise, sore throat, and myalgias. The diagnosis is made by serologic testing. Medical management is with sulfonamides or pyrimethamine.
Tularemia is caused by the organism Francisella tularensis and is transmitted by rabbits, ticks, or contaminated water. Patients present with tonsillitis and painful adenopathy with systemic symptoms of fever, chills, headache, and fatigue. Serologic testing and culture confirm the diagnosis. Streptomycin is the antibiotic of choice.
Brucellosis is caused by a species of gram-negative bacilli, Brucella. It is transmitted most commonly to children by the ingestion of unpasteurized milk. Patients present with total body lymphadenopathy, fever, fatigue, and malaise. Serology and culture are mainstays of diagnosis, and treatment is with trimethoprim–sulfamethoxazole or tetracycline.
The differential diagnoses for granulomatous adenopathy of the neck include cat-scratch disease, actinomycosis, atypical mycobacteria, tuberculosis, atypical tuberculosis, and sarcoidosis.
Cat-scratch disease is caused by the bacterium Rochalimaea henselae. A history of contact with cats can be elicited in 90% of cases. This disease is more commonly seen in patients younger than 20 years. They present with tender lymphadenopathy, fever, and malaise. The lymphadenopathy is typically preauricular and submandibular in location. The diagnosis is made by serologic testing with indirect fluorescent antibodies. Histologically, the cat-scratch bacillus can often be demonstrated by Warthin–Starry staining. Cat-scratch disease is generally benign and self-limited.
Actinomycosis is a gram-positive bacillus. Studies have reported that from 50% to 96% of cases of actinomycosis affect the head and neck regions. Patients present with a painless, fluctuant, neck mass in the submandibular or upper digastric regions. The diagnosis is made by clinical suspicion and biopsy; it is confirmed histologically by the presence of granulomas with sulfur granules. Penicillin is the treatment of choice.
Atypical mycobacteria typically presents in the pediatric population as a unilateral neck mass located in the anterior triangle of the neck or parotid region. These patients have brawny skin, induration, and pain. The diagnosis is made by culture and skin testing. Surgical excision offers definitive treatment, although incision and curettage along with antibiotic therapy constitute an alternative management strategy.
Tuberculosis is seen more commonly in adults than in children. The causative organism is M. tuberculosis. The presenting lymphadenopathy tends to be more diffuse and bilateral in contrast to atypical mycobacteria. Tuberculin skin tests are strongly positive. Cervical tuberculosis is also known as scrofula and is responsive to antituberculous medications.
Sarcoidosis presents most commonly in the second decade of life with lymph node enlargement, fatigue, and weight loss. Chest radiography shows hilar adenopathy. An elevated angiotensin-converting enzyme (ACE) level is seen in 60–90% of patients with sarcoidosis. The diagnosis is confirmed histologically by the presence of noncaseating granulomas on biopsy specimens. Corticosteroids may be used, depending on the severity of the disease.
Immunocompromised patients are particularly susceptible to fungal infections. The most common organisms include Candida, Histoplasma, and Aspergillus. Serology and fungal cultures are imperative for the diagnosis. Aggressive, systemic antifungal therapy with agents such as amphotericin B is the treatment of choice.
Alvi A, Johnson JT. The neck mass: a challenging differential diagnosis. Postgrad Med
. (Outlines the workup of neck masses.)
Barzan L, Tavio M, Tirelli U, Comoretto R. Head and neck manifestations during HIV infection. J Laryngol Otol
. (Reviewed 210 HIV-positive patients. Overall, 84% of the observed patients had head and neck manifestations.)
Emery MT, Newburg JA, Waters RC. Evaluation of the neck mass. J S C Med Assoc
. (Outlines the diagnosis and treatment of neck masses.)
Hazra R, Robson CD, Perez-Atayde AR, Husson RN. Lymphadenitis due to nontuberculous mycobacteria in children: presentation and response to therapy. Clin Infect Dis
. (Discusses the treatment of nontuberculous mycobacteria.)