A 3-year-old boy is brought to the office due to neck swelling. Yesterday, his parents first noticed a small lump on the right side of his neck. Today, the area is red, painful to touch, and larger. The patient had a cough, runny nose, and low-grade fever a week ago, and those symptoms have resolved. When the symptoms appeared, the family had just returned from a family reunion in eastern Arkansas, where several cousins also had a runny nose and fever. The patient has no chronic medical conditions and takes no medications. Immunizations are up to date. Temperature is 38.6 C (101.5 F), blood pressure is 104/74 mm Hg, pulse is 98/min, and respirations are 25/min. On examination, a 5-cm, tender, warm, and poorly mobile anterior cervical lymph node is palpated on the right side. The overlying area is erythematous. Cardiopulmonary examination is normal. The abdomen is soft with no hepatosplenomegaly. The remainder of the examination is normal. Which of the following is the most appropriate treatment for this patient?

Question

A 3-year-old boy is brought to the office due to neck swelling.  Yesterday, his parents first noticed a small lump on the right side of his neck.  Today, the area is red, painful to touch, and larger.  The patient had a cough, runny nose, and low-grade fever a week ago, and those symptoms have resolved.  When the symptoms appeared, the family had just returned from a family reunion in eastern Arkansas, where several cousins also had a runny nose and fever.  The patient has no chronic medical conditions and takes no medications.  Immunizations are up to date.  Temperature is 38.6 C (101.5 F), blood pressure is 104/74 mm Hg, pulse is 98/min, and respirations are 25/min.  On examination, a 5-cm, tender, warm, and poorly mobile anterior cervical lymph node is palpated on the right side.  The overlying area is erythematous.  Cardiopulmonary examination is normal.  The abdomen is soft with no hepatosplenomegaly.  The remainder of the examination is normal.  Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d6c0_f7c9_bc81_4f10d3594811_MD0003_00 This patient has acute, unilateral cervical lymphadenitis, an infection that typically occurs in children age <5. Patients typically have an enlarged (3-6 cm) cervical node that is markedly tender, warm, and erythematous. In some cases, the history may reveal recent upper respiratory symptoms, as in this patient. Fever is often present, but patients are usually well-appearing. Lymphadenitis may progress to suppuration and abscess, which are identified by fluctuance on examination. Diagnosis is usually clinical. The most common pathogens are gram-positive bacteria (eg, Staphylococcus aureus, Streptococcus pyogenes). Anaerobic bacteria can also, but less commonly, cause lymphadenitis in patients with poor dental hygiene via local spread of normal flora from the oropharynx. Empiric antibiotic therapy is typically with clindamycin, which has activity against S pyogenes, methicillin-resistant S aureus (MRSA), and anaerobes. Reasonable alternate regimens include amoxicillin-clavulanate if there is low community MRSA prevalence or a first-generation cephalosporin if there is low likelihood of periodontal disease or dental caries. (Choice A) Azithromycin is used to treat catscratch disease, which presents with chronic, slowly enlarging lymphadenitis after a bite or scratch from a cat, findings that are not seen here. In addition to rifampin, azithromycin is also included in the treatment of nontuberculous mycobacterial lymphadenitis, which most commonly presents in children age <5 as a chronic, violaceous, nontender cervical node. (Choice B) Third-generation cephalosporins (eg, cefdinir) may be used to treat infection caused by S pyogenes but not S aureus or anaerobes. Because these bacteria are clinically indistinguishable, cefdinir is an inappropriate choice for an empiric antibiotic. (Choice D) Itraconazole is used in the treatment of histoplasmosis, a fungal infection acquired in the Mississippi River Valley (ie, central United States). In contrast to the symptoms of acute, unilateral cervical lymphadenitis, symptoms of histoplasmosis range from pulmonary disease with mediastinal lymphadenopathy to hepatosplenomegaly with diffuse lymphadenopathy. (Choice E) Oseltamivir can attenuate symptoms in influenza. Unlike acute, unilateral cervical lymphadenitis, lymphadenitis secondary to influenza is bilateral and presents with both fever and upper respiratory symptoms (eg, cough, rhinorrhea). (Choice F) Supportive care and observation for progression can be considered for acute, unilateral cervical lymphadenitis in an afebrile patient with minimal tenderness or node enlargement. Antibiotics are indicated for this febrile patient with a large, inflamed node at risk for abscess development. Educational objective: Acute, unilateral cervical lymphadenitis is an infection in children age <5 characterized by an enlarged, markedly tender, warm, erythematous cervical node. Empiric antibiotic therapy (eg, clindamycin) should target the most common bacteria, including Staphylococcus aureus, Streptococcus pyogenes, and anaerobes. References: Managing cervical lymphadenitis-a total pain in the neck! (http://www.ncbi.nlm.nih.gov/pubmed/25290125) Pediatric cervical lymphadenopathy. (http://www.ncbi.nlm.nih.gov/pubmed/25213279)

A 3-Year-Old Boy Is Brought to the Office Due to Neck