Acute adenitis in children: clinical course and factors predictive of surgical drainage

Risk Factors for Invasive Interventions in Hospitalized Children With Suppurative Cervical Lymphadenitis

Suppurative cervical lymphadenitis sometimes resolves with oral antibiotic treatment; however, many children are hospitalized for intravenous treatment due to lack of improvement. When there is no substantial improvement, the possibility of a liquefaction process is considered, and as a result, source control such as needle aspiration or open surgical drainage is recommended. We examined, among pediatric patients hospitalized with suppurative cervical lymphadenitis, clinical and laboratory predictors for invasive intervention that may lead to early imaging and intervention, hasten recovery, and shorten length of hospitalization. We compared laboratory and clinical characteristics of pediatric patients hospitalized with suppurative cervical lymphadenitis during 2010-2017, according to 3 treatments: needle aspiration (N = 54), open surgical drainage (N = 37), and conservative adequate antibiotic treatment only (N = 292). Physical indicators such as local erythema and fluctuation were found as predictors for invasive interventions in hospitalized pediatric patients diagnosed with suppurative cervical lymphadenitis. No significant associations were found between invasive interventions and laboratory parameters assessed in this study. Children who underwent interventions displayed a prolonged average length of hospitalization and received extended antibiotic treatment prior to hospital admission. In hospitalized pediatric patients diagnosed with suppurative cervical lymphadenitis, physical examination findings are the main predictive factors for invasive interventions. Consequently, when such straightforward clinical findings are observed in the context of insufficient improvement during antibiotic treatment, they should prompt consideration of invasive intervention.

Clinical and metagenomic characteristics of lymphadenopathy related to fever of unknown origin in children

BACKGROUND

Diagnosis of fever of unknown origin remains challenge for pediatricians. Lymphadenopathy is a separate entity that mainly originates from infection or malignancy.

METHODS

168 patients with FUO accompanied by lymphadenectasis were reviewed. 33 lymph node tissue samples were examined by mNGS. Differences in clinical characteristics were compared among different disease groups. The value of mNGS in diagnosing and improving the clinical situation was assessed.

RESULTS

Multivariate analysis revealed that hepatosplenomegaly and LDH levels were associated with infectious diseases. Arthralgia was correlated with non-infectious inflammatory diseases. Weight loss and a node located in supraclavicular region may indicate neoplastic diseases. mNGS-positive rate was 60.60%, higher than that obtained with traditional methods. Treatment for 3/4 patients was adjusted according to the pathogen detected by mNGS, and antibiotics uses was discontinued or degraded in over 1/2 of the patients according to mNGS results.

CONCLUSIONS

Clinical characteristics of children with lymphadenopathy related to FUO have limited diagnostic value for distinguishing different kinds of diseases, while mNGS of lymph node tissue serves as a useful tool for identifying infectious diseases, especially those caused by rare pathogens. mNGS results can lead to not only adjustments in targeted treatment but also further confirmation of underlying diseases.

IMPACT STATEMENT

1. The clinical features of children with FUO and lymphadenopathy differ according to disease group,although multivariate analysis indicated little diagnostic value for these features. 2. mNGS on lymph node tissue from children with FUO may serve as a efficient tool for distinguishing infectious diseases from other diseases. This is especially useful when a diagnosis cannot be determined with traditional methods. 3. mNGS targeted treatment can be administered in a timely manner and some underlying diseases can be indicated.

Cervical adenitis caused by Staphylococcus aureus in a newborn

Cervical acute lymphadenitis is rarely described in neonates. We present the case of a 12-day-old preterm, fed by nasogastric tube, who presented a tender erythematous submandibular swelling. Laboratory data showed neutrophilia and an elevation of C reactive protein and procalcitonin. Ultrasound findings suggested cellulitis and adenitis with abscess. The culture of the drainage material identified methicillin-sensitive Staphylococcus aureus With the administration of the right antibiotic treatment, a good clinical outcome was observed.

Suppurative cervical lymphadenitis in adult: An analysis of predictors for surgical drainage

OBJECTIVE

Lymphadenitis can be treated successfully by empirical antibiotic therapy. However, inflamed lymph nodes can progress into an abscess with local and/or systemic reaction, which requires more complex treatment strategies. The study aim to analyze possible predictors for abscess formation within inflamed nodes that require surgical drainage.

MATERIALS AND METHODS

We retrospectively enrolled 241 patients with acute or sub-acute cervical lymphadenitis. Demographic including, lymph node characteristics, management, and final diagnosis were recorded. Predictors for abscess formation within the lymph node that required surgical drainage were evaluated using univariate and multivariate analysis. Patient and lymph node characteristics that differentiated suppurative cervical lymphadenitis (SCL) from other lymphadenitis were also analyzed.

RESULTS

There were 41 cases of SCL, 173 cases of uncomplicated cervical lymphadenitis, and 27 cases of tuberculous cervical lymphadenitis (TBLN). Abscess was surgically drained in 39 patients, while 2 patients received a needle aspiration. In 9 patients, SCL complications included cellulitis of the neck soft tissue, supraglottic swelling, internal jugular vein thrombosis, and sepsis. Two patients were diagnosed with melioidosis and actinomycosis after drainage. Multivariate analysis showed that an immunocompromised host, male sex, and receiving prior inadequate treatment were predictors for surgical drainage. TBLN patients had similar manifestations as SCL patients. However, affected nodes in SCL patients were singular, painful, and showed fluctuation.

CONCLUSIONS

Following SCL diagnosis, abscess drainage and appropriate antibiotic treatment should be considered. Aspiration or surgical drainage can be effective in certain patients. Pathogen isolation and tissue biopsy should be performed to ensure accurate diagnosis and antibiotic selection. In addition, TBLN and melioidosis should be considered, especially in endemic areas.

Imaging Strategies and Outcomes in Children Hospitalized with Cervical Lymphadenitis

OBJECTIVES

This study aimed to describe variation in imaging practices and examine the association between early imaging and outcomes in children hospitalized with cervical lymphadenitis.

METHODS

This multicenter cross-sectional study included children between two months and 18 years hospitalized with cervical lymphadenitis between 2013 and 2017. Children with complex chronic conditions, transferred from another institution, and with prior hospitalizations for lymphadenitis were excluded. To examine hospital-level variation, we calculated the proportion of children at each hospital who received any imaging study, early imaging (conducted on day 0 of hospitalization), multiple imaging studies, and CT imaging. Generalized linear or logistic mixed effects models examined the association between early imaging and outcomes (ie, multiple imaging studies, surgical drainage, 30-day readmission, and length of stay) while accounting for patient demographics, markers of illness duration and severity, and clustering by hospital.

RESULTS

Among 10,014 children with cervical lymphadenitis, 61% received early imaging. There was hospital-level variation in imaging practices. Compared with children who did not receive early imaging, children who received early imaging presented increased odds of having multiple imaging studies (adjusted odds ratio [aOR] 3.0; 95% CI: 2.6-3.6), surgical drainage (aOR 1.3, 95%CI: 1.1-1.4), and 30-day readmission for lymphadenitis (aOR 1.5, 95%CI: 1.2-1.9), as well as longer lengths of stay (adjusted rate ratio 1.2, 95%CI: 1.1-1.2).

CONCLUSIONS

Children receiving early imaging had more resource utilization and intervention than those without early imaging. Our findings may represent a cascade effect, in which routinely conducted early imaging prompts clinicians to pursue additional testing and interventions in this population.

Paediatric acute lymphadenitis: Emergency department management and clinical course

Objectives

To describe clinical characteristics and management of acute lymphadenitis and to identify risk factors for complications.

Methods

Health record review of children ≤17 years with acute lymphadenitis (≤2 weeks) in a tertiary paediatric emergency department (2009-2014); 10% of charts were reviewed by a blinded second reviewer. Multivariate logistic regression identified factors associated with intravenous antibiotic treatment, unplanned return visits warranting intervention, and surgical drainage.

Results

Of 1,023 health records, 567 participants with acute lymphadenitis were analyzed. The median age = 4 years (interquartile range [IQR]: 2 to 8 years), and median duration of symptoms = 1.0 day (IQR: 0.5 to 3.0 days). Cervical lymphadenitis was most common. Antibiotics were prescribed in 73.5% of initial visits; 86.9% of participants were discharged home. 29.0% received intravenous antibiotics, 19.3% had unplanned emergency department return visits, and 7.4% underwent surgical drainage. On multivariate analysis, factors associated with intravenous antibiotic use included history of fever (odds ratio [OR]=2.07, 95% confidence interval [CI]: 1.11 to 3.92), size (OR=1.74 per cm, 95% CI: 1.44 to 2.14), age (OR=0.84 per year, 95% CI: 0.76 to 0.92), and prior antibiotic use (OR=4.45, 95% CI: 2.03 to 9.88). The factors associated with unplanned return visit warranting intervention was size (OR=1.30 per cm, 95% CI: 1.06 to 1.59) and age (OR=0.89, 95% CI: 0.80 to 0.97). Factors associated with surgical drainage were age (OR=0.68 per year, 95% CI: 0.53 to 0.83) and size (OR=1.80 per cm, 95% CI: 1.41 to 2.36).

Conclusions

The vast majority of children with acute lymphadenitis were managed with outpatient oral antibiotics and did not require return emergency department visits or surgical drainage. Larger lymph node size and younger age were associated with increased intravenous antibiotic initiation, unplanned return visits warranting intervention and surgical drainage.

Predictors of a drainable suppurative adenitis among children presenting with cervical adenopathy

OBJECTIVES

We sought to identify predictors for a drainable suppurative adenitis [DSA] among patients presenting with acute cervical lymphadenitis.

METHODS

A retrospective cross sectional study of all patients admitted to an urban pediatric tertiary care emergency department over a 15 year period. Otherwise healthy patients who underwent imaging for an evaluation of cervical lymphadenitis were included. Cases were identified using a text-search module followed by manual review. We excluded immunocompromised patients and those with lymphadenopathy felt to be not directly infected (i.e. reactive) or that was not acute (symptom duration >28 days). Data collected included: age, gender, duration of symptoms, highest recorded temperature, physical exam findings, laboratory and imaging results, and surgical findings. A DSA was defined as >1.5 cm in diameter on imaging. We performed binary logistic regression to determine independent clinical predictors of a DSA.

RESULTS

Three hundred sixty-one patients met inclusion criteria. Three hundred six patients (85%) had a CT scan, 55 (15%) had an ultrasound and 33 (9%) had both. DSA was identified in 71 (20%) patients. Clinical features independently associated with a DSA included absence of clinical pharyngitis, WBC >15,000/mm³, age ≤3 years, anterior cervical chain location, largest palpable diameter on exam >3 cm and prior antibiotic treatment of >24 h. The presence of fever, skin erythema, or fluctuance on examination, was not found to be predictive of DSA.

CONCLUSIONS

We identified independent predictors of DSA among children presenting with cervical adenitis. Risk can be stratified into risk groups based on these clinical features.

A clinical decision rule for the use of ultrasound in children presenting with acute inflammatory neck masses

OBJECTIVE

To identify the association between clinical and ultrasound findings and surgical drainage in children with inflammatory neck masses and to create a clinical decision rule that allows for reduction of unnecessary use of ultrasound in inflammatory neck masses.

MATERIALS AND METHODS

We reviewed data on patients ≤18 years who visited our emergency department between 2012 and 2014 with inflammatory neck swelling and who underwent ultrasound examinations of the neck. We used multivariate logistic regression to identify factors associated with drainage within 24 h of ultrasound study (early drainage). Recursive partitioning was used for risk stratification.

RESULTS

Of 341 consecutive patients included in this study, 37 patients underwent early drainage and all had purulent material drained. All patients but one with non-suppurative adenitis and 95% (97/102) of those with suppurative adenitis or early/suspicious abscess on ultrasound were initially treated medically. Of those with a definite diagnosis of abscess/fluid collection, 89% (32/36) underwent early drainage. Patients who underwent drainage were more likely to be younger, female and have a longer duration of neck swelling, with fluctuance and erythema on exam. Recursive partitioning analysis revealed that among children with neck swelling >3 days and ≤3 days, the rate of early drainage was 24.3% and 4.4%, respectively. None of the children >7 months with neck swelling ≤3 days underwent early drainage.

CONCLUSION

Children older than 1 year with inflammatory neck swelling ≤3 days are at low risk of having ultrasound findings that require drainage. In this subgroup of patients, ultrasound could be avoided unless the patient fails to improve after a trial of antibiotic therapy.

Suggested Protocol for Managing Acute Suppurative Cervical Lymphadenitis in Children to Reduce Unnecessary Surgical Interventions

OBJECTIVES

The indications and benefits of surgery in the management of pediatric acute suppurative cervical lymphadenitis (ASCL) remain unclear. We aimed to design a management protocol focusing on the avoidance of unnecessary operation in pediatric ASCL patients.

METHODS

The study population consisted of 45 pediatric patients with ASCL treated with antibiotics alone and 30 surgically treated patients. The primary outcome was the determination of differences in patient characteristics and radiologic findings in the 2 groups. The secondary outcome, after matching 20 cases with 20 controls, was to determine the benefits of surgery to patients.

RESULTS

There were no significant differences between the 2 groups in patient characteristics and radiologic findings at initial presentation. In the matched case-control analysis, intravenous antibiotics alone yielded successful treatment outcomes when compared with surgery, with no significant differences in time to symptom resolution, normalized laboratory test results, and duration of hospitalization (all P > .05).

CONCLUSIONS

The size and location of suppurated lymph nodes are not absolute determinants for surgical drainage in the stable pediatric ASCL patients. If patients show no clinical improvements despite appropriate second- and third-line antibiotics, patients should be carefully reevaluated and image-guided aspiration considered.

Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines

Few studies are available to inform duration of intravenous antibiotics for children and when it is safe and appropriate to switch to oral antibiotics. We have systematically reviewed antibiotic duration and timing of intravenous to oral switch for 36 paediatric infectious diseases and developed evidence-graded recommendations on the basis of the review, guidelines, and expert consensus. We searched databases and obtained information from references identified and relevant guidelines. All eligible studies were assessed for quality. 4090 articles were identified and 170 studies were included. Evidence relating antibiotic duration to outcomes in children for some infections was supported by meta-analyses or randomised controlled trials; in other infections data were from retrospective series only. Criteria for intravenous to oral switch commonly included defervescence and clinical improvement with or without improvement in laboratory markers. Evidence suggests that intravenous to oral switch can occur earlier than previously recommended for some infections. We have synthesised recommendations for antibiotic duration and intravenous to oral switch to support clinical decision making and prospective research.

Imaging of head and neck lymph nodes

The cervical lymph nodes can be affected by a variety of infectious, inflammatory, benign, and malignant pathologic conditions. Clinical history and physical examination with the complementary use of imaging is essential to accurately make a diagnosis or appropriate differential. Knowledge of cervical lymph node anatomy, drainage pathways, morphologic variations, and common nodal pathology is key to correct interpretation of cervical lymph nodes on imaging. Computed tomography (CT), MR, ultrasound, and PET/CT are complementary imaging modalities that can be used in the evaluation of cervical lymph node pathology.

Acute cervical lymphadenitis and infections of the retropharyngeal and parapharyngeal spaces in children

Background

Acute cervical adenitis can evolve into suppurative cervical lymphadenitis and may sometimes be associated with infection of the retropharyngeal and parapharyngeal spaces (i.e., retropharyngeal and poststyloid parapharyngeal abscesses). This study aimed to describe the clinical presentation of acute cervical lymphadenitis and infections of the retropharyngeal and parapharyngeal spaces in children and examine the management of these conditions.

Methods

This was a retrospective study including children from 3 months to 18 years old who were hospitalized in the Pediatric Department of the Centre-Intercommunal-de-Créteil between January 2003 and May 2010. Selected cases were based on the diagnosis of acute cervical lymphadenitis, suppurative cervical lymphadenitis, or infections of the retropharyngeal or parapharyngeal spaces. Case history, clinical signs, laboratory tests, imaging, treatment and clinical course were collected from patient charts.

Results

We included 75 children (54 males [72%]); 62 (83%) were < 6 years old. Diagnoses were acute cervical lymphadenitis in 43 patients (57%), suppurative cervical lymphadenitis in 13 (17%), retropharyngeal or poststyloid parapharyngeal abscess in 18 (24%) and cervical necrotizing fasciitis in 1 (1%). In total, 72 patients (96%) presented fever and 34 (45%) had torticollis. Suppurative cervical lymphadenitis or abscesses of the retropharyngeal or poststyloid parapharyngeal spaces was significantly higher for children with than without torticollis (52.9% vs. 4.8%, p < 0.001). In all, 21 patients among the 44 > 3 years old (48%) underwent a rapid antigen detection test (RADT) for group A beta-hemolytic Streptococcus pyogenes; results for 10 were positive (48%). Contrast-enhanced CT scan of the neck in children with torticollis (n = 31) demonstrated an abscess in 21 (68%). Fine-needle aspiration was performed in 8 patients (11%) and 8 (11%) required surgical drainage. Bacteriology was positive in 8 patients (11%), with a predominance of Staphylococcus aureus and S. pyogenes. All patients received intravenous antibiotics and the outcome was favorable regardless of surgery. Recurrence was observed in only 1 case among the 34 patients with a follow-up visit after discharge.

Conclusion

Our data suggest that presentation with cervical lymphadenitis associated with fever and torticollis requires evaluation by contrast-enhanced CT scan. Furthermore, abscess drainage should be restricted to the most severely affected patients who do not respond to antibiotic therapy.

Management of pediatric lateral neck infections: Does the adage "... never let the sun go down on undrained pus ..." hold true?

OBJECTIVES

Pediatric neck infections are frequently treated by Otolaryngologists, Head and Neck surgeons. The relative role of medical versus surgical treatment of pediatric neck infections is debated. The aims of this study are to analyze the management of pediatric neck infections with respect to clinical assessment, radiological assessment and treatment.

METHODS

Medical records from January 1999 to June 2005 were reviewed and analyzed.

RESULTS

Two hundred and five children with lateral neck infections were included in the study. The clinical diagnosis correlated with the radiology finding in 73.6% with a sensitivity of 28% and a specificity of 92% for lateral neck abscess recognition. The ultrasound finding correlated with the surgical finding in 65.2% with a sensitivity of 70% and a specificity of 33%. When an ultrasound scan was used it changed the intended treatment plan in 10.5% of children.

CONCLUSIONS

Accurate clinical assessment of lateral neck infections is poor, generally under estimating suppuration. However, when an abscess is diagnosed clinically this correlates highly with the surgical finding. Radiological assessment has inaccuracy in identifying suppuration and this should be borne in mind when being used as a diagnostic tool for neck infections.