Unilateral cervical lymphadenopathy

Unilateral cervical lymphadenopathy (UCL) refers to the localized swollen lymph node(s) on one side of the neck and is usually associated with bacterial infections. Acute UCL is most commonly caused by S. aureus and Streptococcus species, while chronic UCL is the result of tuberculous or nontuberculous mycobacterial infections. UCL is most often seen in children under 5 years of age and typically affects the submandibular or deep cervical lymph nodes. In acute UCL, these are often tender, warm, and mobile, and may be accompanied by fever and malaise. Chronically inflamed lymph nodes are typically nontender and become indurated and matted over time. Laboratory tests for inflammatory markers, serology, and bacterial cultures from pus samples are used to monitor the course of the disease and detect pathogens. Biopsies may be needed to rule out malignant etiologies. Most cases of UCL are treated empirically with antibiotics such as clindamycin to cover the most common pathogens. Surgical incision and drainage may be indicated in cases with suppurative lymphadenitis.

• Age: most common in children < 5 years

Epidemiological data refers to the US, unless otherwise specified.

• Most commonly in response to bacterial infections (up to > 80% of cases)
  • Acute Duration < 6 months
    • S. aureus
    • Group A Streptococcus (e.g., Streptococcus pyogenes)
    • Oral anaerobes
    • Group B Streptococcus (GBS)
    • Francisella tularensis
  • Subacute or chronic
    • Nontuberculous mycobacteria (e.g., M. avium-intracellulare and M. scrofulaceum)
    • Mycobacterium tuberculosis
    • Bartonella henselae
    • Toxoplasma gondii
• Kawasaki disease, PFAPA syndrome
• Malignancy: leukemia, lymphoma, metastasis of oral mucosa cancers
• Connective tissue disorders (e.g., juvenile rheumatoid arthritis, systemic lupus erythematosus)

• Usually child appears healthy; possibly history of preceding upper respiratory tract infection or dental conditions
• May have symptoms of an underlying infection (e.g., fever, malaise, tachycardia)
• Lymph node involvement
  • Most common: submandibular or deep cervical nodes (> 80% of cases)
  • 3–6 cm large, tender, warm, possibly erythematous skin over the node
  • Lymph nodes may become fluctuant and form an abscess over time or become indurated.
• Chronic cases: insidious enlargement; nontender, immobile, matted nodes; may form to sinus tracts

• Laboratory tests
  • CBC, ESR, CRP
  • Serology; : if tularemia or cat-scratch disease is suspected
  • Tuberculin test in chronic cases
• Bacterial culture
  • Blood culture
  • Throat swab and oral swab
  • Gram stain and culture of material obtained from fine needle aspiration
  • Histopathological evaluation of sample obtained by excisional biopsy
• Imaging: ultrasound exam or CT scanning

• Unilateral
  • Congenital neck masses
  • Submandibular abscess
  • Thyroid tumors
  • Metastatic cancer
• Bilateral
  • Viral infections: cytomegalovirus, Epstein-Barr virus
  • Streptococcal pharyngitis
  • Toxoplasmosis

The differential diagnoses listed here are not exhaustive.

• Antibiotics
  • Conservative management by active observation for disease regression may be recommendable for children with no fever and non-tender lymphadenopathy.
  • All other cases are treated empirically with oral antibiotics for 10–14 days (e.g., clindamycin)
  • In cases of MRSA or clindamycin-resistance: TMP-SMX, doxycycline
• Supportive therapy: antipyretics, analgesics, warm compresses
• Surgical measures: incision and drainage of large abscesses

1. Cervical Lymphadenitis.