Cervical lymphadenopathy in children L04.0

In the differential diagnosis of regional lymph node swellings in childhood, non-tuberculous mycobacteria (NTM) are found causally with increasing frequency. They lead to lymphadenitis with predominantly cervical, nuchal or axillary enlarged, indurated lymph nodes that persist for weeks, may melt or even rupture. In an immunocompetent child, no systemic manifestations and rarely serious complications are observed. The process is similar to tuberculosis cuits colliquativa, scrofuloderma, which occurs primarily in adults.

In the USA and Western Europe, NTMs are responsible for 85% of mycobacterial diseases of cervical lymph nodes in children. In contrast, pathogens of the M.-tb complex are responsible for <15% (see below Tuberculosis cutis colliquativa). In children with M.-tb lymph node infections, typical risk factors can usually be identified (e.g., contact with a person with pulmonary tuberculosis, travel in a country with a high prevalence of tuberculosis). In a larger study, M. lentiflavum was isolated in 82% and M. avium in 18%. In patients infected with M. lentiflavum, the most common site was submaxillary 43.47%.

m>w; median age of onset is 30.8 months.

Cervical NTM lymphadenitis occurs unilaterally in > 95% of infants and is cervical, submandibular, or paraauricular. In most cases, the lymph node swelling has been present for several weeks at the time of diagnosis. As the disease progresses, a purplish skin coloration appears in the area of the affected lymph node. Spontaneous perforation or fistulization to the outside with discharge of putrid material is not uncommon. The lymph node texture is usually firm but may fluctuate with abscessation. Multiple nearby lymph nodes, often extending far into the depths and poorly demarcated, are also frequently involved. Pressure pain is rather rare. The general condition is usually not disturbed.

Blood count with, if possible, manual microscopic differential blood count as well as reticulocyte and reticulocyte production index (RPI).

CRP, ESR, creatinine, LDH (elevated in primary EBV infection and malignancies), uric acid (hyperuricemia due to tumor lysis syndrome in malignancies)

In case of a suitable clinic or anamnesis: serology for EBV, CMV, B. henselae and Toxoplasma.

In case of anamnestic or clinical indications: serology for HIV, tuberculin skin test (THT) (2TU PPD-RT 23) or interferon-gamma-release assay (IGRA)

Ultrasound examination of the lymph node, if possible with Doppler sonography (in the case of increased central blood flow or melting, indicative of an infectious cause; in the case of abolished lymph node base structure, in the case of round instead of oval lymph node structure (short axis-to-long axis ratio; S/L ratio), peripheral blood flow pattern, possibly indicative of a malignant disease

if necessary, X-ray examination of the thorax (in 2 planes)

Differentiation from lymphadenitis of other causes, especially a tuberculous form, can be difficult. A definitive diagnosis can only be made by pathogen detection in the punctate or bioptate.

NTMs respond poorly to therapy with antibiotics or tuberculostatics. The treatment of choice is surgical removal of affected lymph nodes.

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5. Oguz A et al (2006). Evaluation of peripheral lymphadenopathy in children. Pediatr Hematol Oncol 23: 549-561