Lymphadenopathy

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Chapter 30 LYMPHADENOPATHY

Theodore X. O’Connell

General Discussion

Lymph nodes in children may be palpated as early as the neonatal period, and they continue to enlarge through puberty. Most normal children have palpable cervical, inguinal, and axillary adenopathy. As a general rule, a lymph node is considered enlarged if it measures more than 10 mm in its longest diameter. Exceptions to this rule include epitrochlear nodes, which are abnormal if greater than 5 mm in diameter, and inguinal nodes, which are abnormal only if greater than 15 mm in diameter. Palpable supraclavicular, iliac, and popliteal nodes should always be considered abnormal.

Hyperplastic lymph nodes that develop in response to viral infection are small, discrete, mobile, nontender, and bilateral. Pyogenic nodes tend to be unilateral, large, warm, and tender with surrounding erythema and edema. Chronic infections are associated with nodes with discrete margins adherent to underlying tissue and minimal signs of inflammation. Nodes associated with malignancy are generally firm, discrete, and nontender. These nodes are usually rubbery and do not have surrounding inflammation. These nodes become matted together over time and fixed to the skin or underlying structures.

In general, rapidly growing lymph nodes without a confirmed, compatible diagnosis require prompt tissue biopsy. Regressing or fluctuating lymphadenopathy usually can be observed as it is rarely associated with malignancy or serious systemic illness. However, if the lymphadenopathy persists and a diagnosis is required, biopsy is the most definitive option. Persistent lymphadenopathy beyond 8 weeks without an obvious source also should be considered for biopsy.

Causes of Lymphadenopathy

• Branchial cleft cyst

• Bronchogenic cyst

• Cystic hygroma

• Epidermoid cyst

• Sternocleidomastoid tumor

• Thyroglossal duct cyst

• Aspergillosis

• Blastomycosis

• Coccidioidomycosis

• Cryptococcus

• Histoplasmosis

• Sporotrichosis

• Toxoplasmosis

Suggested Work-up

Complete blood count (CBC)	To evaluate for infection or malignancy
Biopsy by fine-needle, core-needle, or open biopsy	If malignancy is suspected or if the diagnosis remains in doubt after a thorough evaluation
Gram stain and cultures for aerobic, anaerobic, acid-fast (tuberculous), and fungal microorganisms	After drainage when suppurative adenopathy is present
Histologic examination	If there is any suspicion of malignancy, a portion of the suppurated lymph node that is not necrotic should be examined histologically
Surgical excision with histologic examination	If atypical mycobacterial lymphadenitis is suspected
Chest radiograph and intradermal skin testing	If tuberculous lymphadenopathy is suspected
Indirect fluorescent antibody test for Bartonella spp. antigen	If cat scratch disease is suspected
Computed tomography (CT) scan	To evaluate large mediastinal masses
Magnetic resonance imaging (MRI)	May be a better diagnostic tool for posterior mediastinal masses
Biopsy by mediastinoscopy, thoracoscopy, or thoracotomy	If mediastinal mass/lymphadenopathy is present
Open or laparoscopic biopsy	If abdominal lymphadenopathy is present

1. Kelly C.S., Kelly R.E. Lymphadenopathy in children. Pediatr Clin North Am. 1998;45:875–888.

2. Grossman M., Shiramizu B. Evaluation of lymphadenopathy in children. Curr Opin Pediatr. 1994;6:68–76.

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