Inflammatory Neck Masses

Reactive lymph nodes from a viral infection should be treated expectantly, whereas bacterial infections such as streptococcal tonsillitis or pharyngitis should be treated with appropriate antibiotics. In some cases, inflamed lymph nodes can suppurate and become abscessed, requiring incision and drainage. Masses thought to be reactive lymph nodes not responding to conservative management (antibiotics) often need referral for further evaluation to obtain a definitive diagnosis.

Cervical lymphadenitis can be caused by atypical myco-bacteria, which may appear as a subcutaneous abscess with erythematous overlying skin (Fig. 19-9). Treatment includes excisional biopsy and appropriate antibiotics according to culture sensitivities. Incisional drainage is contraindicated and can cause chronic fistulization.

Cat-scratch disease is another pediatric infection that can manifest with lymphadenopathy. Most patients recount exposure to a cat, and many have a cutaneous lesion representing an inoculation site. The diagnosis is made by serologic testing for Bartonella henselae. The disease is self-limited.

Tuberculous cervical lymphadenitis (scrofula), caused by Mycobacterium tuberculosis, can manifest with bilateral lower lymph node enlargement. It is usually associated with pul-

Figure 19-9 Photograph showing cervical adenitis with overlying skin erythema in a young child. Cultures revealed atypical mycobacteria.

monary involvement, and treatment is with a multidrug regimen. Nodes not responding to treatment should be excised.

Patients infected with human immunodeficiency virus (HIV) can present with asymptomatic lymph node enlargement. Persistent lymphadenopathy in AIDS patients is common, and most are followed if the nodes remain stable. Because of the higher incidence of non-Hodgkin's lymphoma and Kapo-si's sarcoma in these patients, any suspicious neck masses with other constitutional symptoms should be referred for biopsy and tissue diagnosis. Fine-needle aspiration biopsy is appropriate, with indeterminate cytology requiring open excisional biopsy. Other possible causes of neck lymphade-nopathy in immunocompromised patients include histo-plasmosis, tuberculosis, atypical mycobacterial infections, and toxoplasmosis.

Sarcoidosis is a granulomatous disease that causes cervical lymphadenopathy and may be the presenting sign in 10% to 15% of cases. This disorder typically affects the African American population. Other findings include fever, sinusitis, parotid swelling, and hilar adenopathy on chest x-ray films. Diagnosis is classically made by tissue biopsy showing non-caseating granulomas. High angiotensin-converting enzyme level is common but not diagnostic. Other studies include cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) to rule out other granulomatous diseases, purified protein derivative and acid-fast bacillus stains to rule out tuberculosis, and Venereal Disease Research Laboratory (VRDL) and RPR tests to exclude syphilis.

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