Pediatric Lymphadenopathy

As has been highlighted in prior Morsels, our job in the Ped ED is to use our expert skills to pick out the needles of significant disease from amongst the large haystack of benign conditions. Lymphadenopathy occurring in our pediatric patients is another great example of this notion.

Fortunately, the leading causes of enlarged lymph nodes (particularly cervical) will be reactive lymphadenopathy and acute lymphadenitis from viral and bacterial infections; however, the silent concern that has lead the parent/guardian to bring the child in for evaluation is the possibility that this may represent a malignancy.

What characteristics should raise concern for malignancy?

History:

• Systemic symptoms – fatigue, weight loss, night sweats – can help, but can also be seen with infections
• Lack of exposure to infectious agents (naturally) – Strep Pharyngitis, Mono, Cat-Scratch disease
• Duration – greater than 4 weeks warrants concern, but inflammatory nodes can be present for up to 6 months.

Physical Exam:

• Characteristics of the specific node:
  • Larger than 3cm in diameter
  • Supraclavicular location
  • Non-painful
  • Progressively enlarging
  • Firm
  • Fixed in location (not mobile)
  • Ulcerations
• Other findings:
  • Generalized lymphadenopathy
  • Hepatosplenomegaly
  • Pallor
  • Goiter
  • Failure to thrive

Fortunately, for the greatest majority of children presenting because of “neck mass,” you are likely going to determine it is due to recent viral illness and is reactive lymphadenopathy.  Occasionally, it will be an infected lymph node and require antibiotics. With that being stated, it is still imperative that we proceed as if we are looking for these signs of malignancy… because that is likely what the parents are concerned with.  Document the presence or lack of them and proceed accordingly.  Fortunately, even when some of these characteristics are present, it still will be due to a benign illness (they are sensitive not specific traits).