A 4-year-old girl is brought to the clinic due to swelling on the neck. The mother first felt a few lumps on the patient's neck 2 days ago while brushing her hair. Their size has not changed. The patient has had no recent fever, cough, rhinorrhea, or sore throat. She goes to preschool. The family has not traveled outside of the United States. Temperature is 36.6 C (97.9 F), blood pressure is 94/66 mm Hg, pulse is 78/min, and respirations are 14/min. Physical examination shows several nontender, soft, mobile, subcentimeter anterior cervical lymph nodes bilaterally. The oropharynx is clear and cardiopulmonary examination is normal. There is no hepatosplenomegaly. The remainder of the examination is unremarkable. Which of the following is the best next step in management of this patient's examination findings?
Lymph node features | ||
Reassuring | Worrisome | |
Palpation |
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Location |
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Systemic symptoms** |
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*Exception: supraclavicular nodes. **Examples include fever & weight loss. | ||
Palpable peripheral lymph nodes are common in children and young adults. Reassuring features include palpation revealing small (<2 cm in diameter), soft, and mobile nodes that are localized to one area.
On the other hand, any abnormal lymph node findings, including those related to size, quality, location, and progression, signify lymphadenopathy. Malignant lymph nodes tend to be firm, immobile, and large (>2 cm in diameter). Systemic findings (eg, fever, night sweats, unexplained weight loss) are often present. Generalized lymphadenopathy is also worrisome and suggests malignancy or infection (eg, cytomegalovirus). Although localized lymph nodes are typically benign, palpable supraclavicular lymph nodes should be considered pathologic until proved otherwise because they are associated with gastrointestinal, genitourinary, and pulmonary malignancies.
Because this child has normal (ie, soft, mobile, <1 cm) cervical lymph nodes and no systemic findings, management should consist of reassurance and observation. Most palpable lymph nodes are benign and regress within several weeks.
(Choice A) This patient has normal lymph node findings (ie, no lymphadenopathy), so laboratory evaluation is not warranted. If this patient develops abnormal features (eg, firm, immobile, and large nodes), management may include a complete blood count to assess for malignancy or occult infection.
(Choice B) Antibiotic therapy is warranted for lymphadenitis, which is characterized by tender, enlarged, warm nodes. This patient has no signs of infection and does not need antibiotics.
(Choice C) Classic symptoms of infectious mononucleosis include fever, pharyngitis, and posterior cervical lymphadenopathy. Diagnosis is typically based on clinical findings and/or positive Monospot testing for Epstein-Barr virus. However, this patient is asymptomatic, so testing is not warranted.
(Choice E) Group A streptococcal (GAS) pharyngitis may present with anterior cervical lymphadenopathy, as well as the classic symptoms of fever, sore throat, abdominal pain, and headache. Unlike the lymph nodes in this patient, the nodes in GAS pharyngitis are typically enlarged and tender. In addition, this patient has no other symptoms of GAS infection, so testing is not indicated.
Educational objective:
Palpable cervical lymph nodes are common in children and young adults. In the absence of worrisome features (eg, >2 cm, firm, immobile lymph nodes; systemic symptoms), palpable lymph nodes can be observed for resolution.