Cervical Adenitis Andrew M. Margileth Pediatrics in Review 1985;7;13 DOI: 10.1542/pir.

7-1-13

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Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1985 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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Cervical
Andrew

Adenitis
MD*
guinal node 1 5 mm or less is likely to be normal. This paper will review the etiology, clinical presentations and manifestations, differential diagnosis, diagnostic evaluation, and management of children and adolescents with enlargement of cervical lymph glands associated with more common infections. Recent review articles have discussed cervical lymphadenopathy associated with less common infectious disorders and with systemic disease, and also the problem of congenital and acquired noninfectious cervical masses or cysts. Only a few of these lesions will be mentioned in the differential diagnosis of cervical lymph gland enlargement. a primary oropharyngeal from serologic data. Subacute or chronic
enitis, which develops

M. Margileth,

Children with acutely tender and inflamed cervical lymph nodes are observed commonly by family physicians and pediatricians. Cervical lymphadenitis is usually associated with a systemic viral illness and subsides within a few days to 2 weeks. Bacterial adenitis, seen less often, is usually due to (3-hemolytic streptococcal or to staphylococcal infection. However, when a neck node remains enlarged following a systemic illness or when a nontender regional cervical node (adenopathy) persists longer than 2 or 3 weeks with or without associated illness, the physician and parents become worried. Concern is enhanced if the nodes increase in size or number. Infection and inflammation are the most common causes for persistent chronic (3 or more weeks
duration) lymphadenopathy in chil-

INCIDENCE

AND

ETIOLOGY

lesion, cervical
slowly

on adover

dren. Whereas neoplasm is rare (1 .4%) in the child or adolescent less than 1 7 years of age with a superficial mp on any part of the body, maligancy (Hodgkin disease, lymphoma, neuroblastoma) was found in 31 (1 3%) of 239 enlarged cervical nodes in similar-aged children at the same institution. Congenital and acquired cysts, pilomatnixomas, and benign neoplasms (lipoma, neurofibroma, lymphangioma) account for the majonity of noninflammatony lesions in the neck in children and adolescents. However, most cervical lymphadenopathy in children is due to adenitis or reactive hyperplasia in response to an infection. Lymphadenopathy in children is defined as a nontender lymph node larger than 10 mm in most anatomic sites. Two exceptions are: (1) an epitrochlear node 5 mm or larger is considered abnormal, whereas an in-

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the F. Edward H#{233}bert School of Medicine, Uniformed Services University of the Health Sciences or of the Department of Dense. Department of Pediatrics, Uniformed Services University of the Health Sciences, F. Edward H#{233}bert School of Medicine, Bethesda, MD 208 14-4799.

Bacterial cervical adenitis is pnimarily caused by Staphylococcus aureus, group A f3-hemolytic streptococci or both. Facial or oral trauma, impetigo, or tonsillitis may be the etiologic source. Anaerobic bacteria may cause lymphadenitis, usually in association with dental caries and penodontal disease. Anaerobic cultures should be obtained on all material aspirated from an enlarged lymph node, inasmuch as anaerobes outnumber aerobes ten to one in the normal oropharyngeal flora. EpsteinBarr viral infection is relatively common in the older child and adolescent with posterior cervical adenitis with or without generalized adenopathy. Uncommonly, group B f3-hemolytic streptococci or Gram-negative bacilli may cause acute cervical adenitis in the neonate; S aureus infection is more common in older infants. Rarely, other organisms such as Haemophilus influenzae type b, Francisella tularensis, Corynebacterium diphtheriae, Yersinia species, and AcinetobaCter calCoacetiCus (Mima) can be isolated (Table 1). Prevalence of unusual bacterial, fungal, chlamydial, mycoplasmal, and spirochaetal lymph node infections varies by geographic location and age of the patient. Viral etiology is presumed with recovery of the virus from
pediatrics

two or more weeks may be due to S aureus, anaerobic bacteria, EpsteinBarr virus (EBV), or cytomegalovirus (CMV). More often it is caused by cat-seratch disease, nontubenculous
mycobactenia, and uncommonly by

Mycobacterium tuberculosis (TB), Toxoplasma gondii, histoplasmosis, Chlamydia trachomatis or tropical protozoal infections, varying with geographic location. Infection of negional lymph nodes associated with an inoculative skin lesion (lymphocutaneous syndrome) or a conjunctival lesion or conjunctivitis (Paninauds oculoglandular syndrome) suggest infection due to cat-scratch disease, tuberculosis, Chlamydia, noCardia, tulanemia, sporotnichosis, or cutaneous leishmaniasis.
PATHOGENESIS PATHOLOGY AND

The major portal of entry of microorganisms that produce most childhood infections is the upper respiratory tract. Marcy reviewed the threetiered lymphatic system of the onopharynx and cervical areas that has evolved to defend against microbial invasion, and noted that infection of the three Ts-tonsils, teeth, on areas
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Cervical Adenitis

TABLE 1. Cervical Infectious Organisms

Adenitis in Children and Adolescents: Etiology of and Usual Time Interval to Development of Disease0
Subacute/Chronic Lymphadenitis Onset: Gradual, 1 to 3 wk

Acute Lymphadenitis Onset: Rapid, 1 to7d

Common Staphylococcus aureus Group A f.-hemoIytic streptococci

Anaerobes

Common
Gram-negative pleomorphic bacillus

(cat-scratch

disease)

Adenovirus Cytomegalovirus
Enteroviruses

Epstein-Barr

virus

Less common Staphylococcus aureus Epstein-Barr virus

Cytomegalovirus

Herpes simplex Vanicella

Uncommon Chlamydia trachomatis: Iymphogranuloma venereum Gram-negative bacilli Group B streptococci Group C streptococci Mycoplasma hominis Pasteurella multocida Rare Acinetobacter calcoaceticus a-Hemolytic streptococci Bacillus anthracis Brucella species Corynebacterium diphtheriae Haemophllus inf!uenzae, type b Francisella tularensis Nocardia species: Act inomyces israelll Spin//urn minor Yersinia species from Marcy.

Uncommon Mycobacteniurn M fortuiturn M maninurn M scnofu!aceurn M tuberculosis

Anaerobic

aviurn-intnacellulare

bacteria

Rare Aspergillus fumigatus Candida albicans Coccidioides irnrnitis Histoplasrna capsulaturn Leishrnania tropica, brazillensis, donovani Pseudornonas pseudornallei (meliodiosis) Rickettsia akani (Rickettsialpox) Toxoplasma gondii Treponema pallidiurn

recent earache was reported in 55 of 74 children (74%). The primary sit of bacterial lymphadenitis due to aureus or 3-hemoIytic streptococcus was noted most often in the submandibular (50%) and anterior cervical (30%) areas. Posterior cervical (9%), submental (8%), and occipital area (3%) involvement were observed less often. Concurrent findings on physical examination were otitis media (1 6%), tonsillopharyngitis (39%), impetigo (32%), and noncervical lymphadenopathy (32%). Clinically, there are few findings to help differentiate cervical adenitis due to S aureus fnom that due to f3-hemolytic streptococci, although patients with S aureus infections tend to have a longer duration of symptoms (ten days v four days) and an increased incidence of fluctuation of the involved node at the initial presentation. The infected node vanies from 2.5 to 6 cm in diameter, and tenderness is common, usually associated with increased warmth and enythema of the overlying skin. Cervical edema may be marked, so that

the node(s) may not be palpable. Bilateral acute cervical adenitis usuall is caused by viral upper nespirato tract infections or group A streptococcal phanyngitis. The overlying skin

of trauma (including self-inflicted scratch marks)-is often accompanied by cervicofacial adenitis in children. Adenopathy develops following tissue invasion by the microorganisms and their entry into the lymphatic system. Inflammation of the lymph node results as the microbes are trapped and destroyed by phagocytes and by the intense lymphocytic proliferation and cell transformation that accompanies associated immunologic response. In some patients, abundant infiltration of neutrophilic leukocytes results in suppuration and abscess formation. Acute peniadenitis and inflammation of overlying skin are often seen early with S aureus and group A 13-hemolytic
stneptococcal infections, less often

reactions, may microabscesses

scesses over

slowly develop and/or frank

several weeks

into
abon

months. After resolution of the infection and inflammation, healing occurs with fibrous tissue fonmation. Firm, fibrous nodes may persist for many months or years and have no pathologic significance. CLINICAL Acute MANIFESTATIONS Lymphadenitis

Cervical

with infection due to the cat-scratch bacillus or mycobacteria. The latter, associated with delayed cellular immune response and gnanulomatous
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The usual clinical presentation is low-grade on no fever, irritability, malaise, and tenden, unilateral node swelling. High fever, stiff neck, anorexia, and toxicity are seen occasionally in the younger child. Sore throat, upper respiratory tract infection, and recent skin infections are observed less commonly; the incidence of each varies from 25% to 34%. In the same study, a history of

is usually normal. Rarely, a scarlatinifonm rash may be observed with either S aureus on stneptococcal infection. Recently, a cellulitis-adenitis syndrome caused by group B streptococci was described in 1 to 2-monthold infants; this syndrome was associated with irritability, fever, anorexia, and facial or submandibular cellulitis and adenitis. Bacteremia occurred frequently and otitis media was common. Cervical adenitis in the neonate is usually due to S aureus. Rarely, cervical adenitis may be seen due to anthrax, bubonic plague, histoplasmosis, Pasteure!la mu/tocida (dog or cat bite), nat-bite fever (Spirillum minor), nickettsialpox, tulanemia, or syphilis. These disorders may have a characteristic skin lesion at the site of inoculation and may be recognized as one of the lymphocutaneous syndromes. Herpes simplex adenitis is usually submandibular wit associated gingivostomatitis and/o anterior shallow ulcers of the mucous membrane. The presence of poste-

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NFECTIOUS

DISEASE

non oral and/or anterior pillar,discrete, 1 to 2 mm, shallow ulcers or greyish papules and vesicopustules on an erythematous base with cervical adenitis suggests a coxsackie on ECHO viral infection. In the rare situation of a child with recurrent cervical adenitis due to S epidermidis, Serratia, Gram-negative enteric bacteria, Candida, or Aspergil/us, a defect in gnanulocyte function should be investigated.
Chronic Lymphadenitis
Fig 2 (Right). Boy with cat-scratch disease. Multiple anterior and posterior cervical adenopathy (about 25 enlarged nodes) seen in healthy 5-year-old who had received muitiple scalp insect bites and cat scratches during previous month. Antistreptolysin titer and serologic studies for Epstein-Barr virus, cytomegalovirus, toxoplasmosis, and fungal diseases resulted in negative or normal findings on repeated tests. Results of PPD skin tests were negative, but two cat-scratch skin tests produced positive results. Adenopathy subsided after 5 months without specific treatment.

The most common subacute or chronic lymph node infections in the face on neck are due to cat-scratch disease, nontuberculous mycobactena on tuberculosis. Toxoplasmosis, histoplasmosis, Epstein-Barr viral and cytomegalovinal cervical node infections occur less often (Table 1). When regional adenitis occurs associated with an indolent, crusted papule, vesicopustule or an ulcer, catscratch disease is usually the cause. Rabbit- or tick-borne ulcenoglandular tulanemia must always be considred. In the United States protracted
mphocutaneous disease rarely may

be due to herpes simplex, syphilis, human tuberculous infection, sporotnichosis, histoplasmosis, coccidioidomycosis, diphtheria, nocandia, ratbite fever, lymphognanuloma venereum, anthrax, or cutaneous leishmaniasis. Cat-Scratch Disease

Fig 3. Lymph node section in clumps in endothelial cells stain [AFIP-MIS 84-7473]). disease bacilli singly and in stain [AFIP MIS 84-7543]).

from patient with cat-scratch disease. Left, Note bacilli, singly and that outline vessel(x 180); Warthin-Starry silver (WSS) impregnation Right, Step-section of node cut at same level shows cat-scratch clumps in areas of necrosis (x 1,000; Brown-Hopps tissue Gram

Cat-scratch disease is a zoonotic infection characterized by a skin papule at the site of the scratch (from a cat in 90% of cases) followed in five to 50 days by regional lymphadenitis (Figs 1 and 2). A primary inoculation lesion found in 31 2 of 548 patients (57%) may have resolved by the time adenitis is detected. Identical Gramnegative, pleomonphic bacilli have been demonstrated in the primary skin lesion and in regional lymph nodes (Fig 3). We have found single (39%) or multiple (24%), tender (80%), enlarged (1 to 7 cm) nodes in the head on neck in 318 of 548 patients (58%) (Fig 4). In spite of imressive lymphadenopathy, the palent usually appears well. No signs or symptoms except adenopathy occurred in 274 of 548 patients (50%)

(Table 2). Fever, malaise, and/or fatigue were noted in about 30% of these patients. An exanthem (maculopapular, petechial, erythema multifonme, or nodosum) lasting four to nine days was observed in 4% of these patients. Intraparotid adenitis (lymphosialoadenopathy) occurred in 1 1 of 464 patients (2.4%). Males predominated over females, 61 % to 39%, and 471 of 548 patients (86%) were less than 21 years of age. Lymphangitis has not been reported in cat-scratch disease. Node suppunation occurs in about 15% of patients, during which time the overlying skin can be red and warm (Fig 5). Spontaneous resolution of catscratch disease adenitis usually occurs (54%) over a 2- to 6-month penod, but may persist 6 to 24 months in 20% of patients. pediatrics in review
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Cervical

Adenitis

healing

23 year old had posterior cervical skin puncture from cat scratches in had suppurative Fever (39.4#{176}C to therapy with cefadroxil and! by seven cats. PPD-Battey showed 17mm of induration. with resolution of adenitis in 3 healthy child

4V2-year-old

performed

enitis, occasionally with down and ulceration (Fig more frequently (74%) culous mycobactenial patients with TB more of the latter to have large ( cm) Toxoplasmosis In contrast vical adenitis
mononucleosis,

breakoccurred nontuberthan found

usual

presentation of cat-scratch diswas found in 49 patients (5.5%) It was manifested by either an granuloma, papilloma, or nonconjunctivitis with pa-

to acute caused
rubella,

area swelling

due to preaunicular

Lymphadenitis

Nontuberculous
syndrome of Parinaud is in year-old who had 20-mm granuloma for 2 weeks and preauricular adenitis for two days. licks occurred. No therapy was given. of granuloma revealed epithelial ulceration, cal subepitheli#{225}l necrosis, and infiltration substantia propria with lymphocytes plasma ceils. Warthin-Starry and stains revealed multiple clumps of bacilli. Cat-scratch antigen test results positive and adenopathy resolved neously in 3 months.

mycobactenial

ad-

enitis occurred in 152 (86%) subjects in contrast to 24 patients (14%) with tuberculous adenitis (Table 4). There

were
two

some
groups.

bus
than

adenitis
5 years

differences between the Patients with tubencutended to be older (more

of age) and other family

tion, or infected insect adenitis secondary to usually presents as a den, posterior node. Most asymptomatic. A raw or rare meat or close a cat or its feces may careful examination of chronic seborrhea, tinea head lice should be the United States,
tis and African

cerinfectious infecchronic nontenare of eating with A scalp for or Outside adeni-

Atypical cat-scratch curred in 9% (84/891) (Table 3). Paninauds syndrome, the most
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tests mymore often (82%) in mandibular (Fig 7) and anterior cervical areas compared with tubercubous adenitis (50%). The latter was observed in posterior cervical locations in 17% compared with 9% of patients with nontubercubous mycobactenial adenitis. Fluctuating adno. 1 july 1985

members had positive PPD twice as often. Nontubercubous cobactenial adenitis occurred

should

be considered.

DIAGNOSTIC Initial Visit

The child who cervical adenitis apparent systemic diagnostic enigma.

is first is often a medi-

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INFECTIOUS

DISEASE

TABLE 4. Major Clinical Features of Tubercubous Patients (January 1967 to September 1984)

Lymphadenitis

in 176

Nontuberculous Mycobacteria Clinical Features

(N
=

152)

Mycobacterium tuberculosis (N = 24)

No. (%) Age <2 27 (18)

No. (%) 3 (12)

2-4 5-11 >12 Adenopathy Mandibular

Anterior cervical

97 23 5 68 57 12 13 74 64 36 35

(64) (15) (3) (45) (37) (8) (9) (49) (42) (24) (23)

6 10 5 5 7 2 4 9 13 7 5 3

(25) (42) (21) (21) (29) (8) (17) (38) (54) (29) (21) (13)

Preauncular Posterior cervical

Other sites

2* (1)

6t (25)

Tender Duration: 1 to <4 wk Fever (38.3#{176}C) Pharyngitis-upper respiratory

infection

Fig 7. Infant with nontuberculous mycobacterial, bilateral submandibular adenitis for 7 weeks. Excisional biopsies in this healthy 21month-old infant revealed necrotizing granulomas with negative stains for acid-fast bacilli and fungi in each lymph node. Culture results were negative. PPD skin tests revealed PPDBattey antigen 24 mm and PPD-T 7 mm. Catscratch skin test findings were negative. Patient was fully recovered 3 years later.

tract

Skin lesion (sinus, abscess) Epitrochlear (one) and axillary and epitrochlear
0

27 (18) (one).
(one).

t Axillary

(three),

inguinal

(two),

and mediastinal

cab history to ascertain preceding ore throat, upper respiratory tract fection, animal or bird exposure, skin or dental problems, insect bites or pet scratches, TB contact, drug usage (Dilantin), foreign travel, and duration of adenopathy is essential.
It is important to determine whether chronic or recurrent adenopathy has

information include: (1 ) complete blood count, (2) sedimentation rate, (3) throat culture, and (4) blood culture. If the child is not ill, a blood and/or throat culture may be unnecessary but reexamination is recommended in three to four days, sooner helpful if indicated (Fig 9). Additional studies

ever occurred in the past. A complete physical examination is necessary to detect dental on skin disease, ocular or oropharyngeal disease, noncervical adenopathy and hepatosplenomegaly. Careful palpation of the cervical mass is essential to determine exact anatomic location and number of nodes, presence of tenderness,
mobility (fixation to skin or subcuta-

neous tissue), size in two dimensions, and consistency (soft or firm, solid or cystic, fluctuating or not). Bimanual palpation of a mass in the cheek or mandibular area is helpful. Transillumination should always be considered. Ultrasound may be useful in establishing whether the mass is solid, cystic, or fluctuating; it may help to identify localized pus. In the moderately or severely ill
hild, especially in cases in which the

such as Mono-Vacc on Tine test and reexamination at intervals of several days to weeks, depending upon the individual circumstances of each case and results of hematobogic, serologic, and/or bacteriologic tests, are outlined in Fig 9. Aspiration and culture of an inflamed node can be rewarding and is easily accomplished; complications are rare. After cleansing the skin, needle aspiration using an indirect (side-door) approach (a No. 20 needle
is passed through 2 to 2.5 cm of

Fig 8. Ulcerative skin lesion in healthy asymptomatic 2-year-old who had incision and drainage for fluctuating posterior neck mass present for 4 weeks. Keflex therapy was not effective. Tine test findings were negative; findings on chest roentgenogram were normal. Culture was negative for aerobes, anaerobes, and fungi. Mycobacterium avium-intracellulare was isolated after 8 weeks. PPD-Battey was 28 mm; PPD-T was 19 mm. No antituberculous therapy was given. Excisional biopsy was effective and patient was well 4 years later.

Differential

Diagnosis:

Diagnostic

Considerations Noninfectious causes of chronic cervical adenopathy were less commonly observed in our 1 7-year study than were infectious causes (Table 5). The congenital and acquired cysts, neoplasms, and miscellaneous disorders simulating adenopathy, and/or systemic diseases in which prominent cervical adenitis may occur are tabulated (Table 6). If a thyrogbossal on branchial cleft cyst becomes infected, diagnostic confusion can occur. It is difficult in the presence of acute inflammation and edema to differentiate large ( 3 cm) cervical
#{149}

cervical node is large ( 3 cm), initial laboratory tests that may provide

normal subcutaneous tissue, entering at the base of the enlarged node) may yield enough material for smear and cultures. If no tissue fluid or pus is obtained, 0.5 to 1 mL of normal, nonbacteniostatic saline is injected using a separate 1 0-mL syringe and reaspiration is done. Aspirated matenial should be cultured for aerobic and anaerobic bacteria, mycobactena, and fungi.
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Cervical

Adenitis

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NFECTIOUS

DISEASE

TABLE

5.

Diagnostic

Groups

of 1 ,200 Patients

with

Chronic

Lymphadenopathy (Cervical and Noncervical) or Subcutaneous Mass SkinTested with PPD-T, PPD-Nontubercubous Mycobacterial, and Cat-Scratch Antigens (January 1967 Through September 1984)
Group Diagnosis Skin Test No. (%)

I
II

Ill IV
Total
0

Cat-scratch disease Nontuberculous lymphadenitis Mycobactenium tuberculosis lymphadenitis Other diseases0

(64) bacterial, viral, toxoplasmosis; cysts

Positive Positive Positive Negative

(1 5); tumors

891 (74) 152(13) 24(2) 133(11) 1,200(100)

(1 3, benign

Adenitis

(seven) and malignant (six); Hodgkin disease (1 2); reactive hyperplasia (ten); sarcoidosis (four); leukemia (four); hilar adenopathy (four); granuloma annulare, lues (three); Iymphgranuloma venereum (two); neurofibroma, cervical (two).

nodes Careful tions,

studies

from infected cysts (Fig 10). observation, serial examinaand appropriate laboratory
can be helpful. Acute parotitis

TABLE 6. Chronic Adenopathy and/or Subcutaneous Cervical Lesions in 57 Children and

Adolescents Nontubercubous with Negative PPDMycobacterial,

with an elevated serum amylase level; dental films usuIly will identify a peniapical abscess. eoplasms of thyroid, salivary, or subcutaneous tissues will not be identified until histologic examination is done. The importance of age, bocation, and frequency of cysts and malignant neck tumors has been reviewed by Knight et al and Zitelli. Diagnostic features of ten infectious lymphadenopathies that physicians may encounter in children and adolescents are noted in Table 7. It is not necessary to establish the cause of cervical adenitis in each patient. In the otherwise healthy child whose node(s) is only minimally enbanged (< 2 cm) and/or tender, is discrete, is mobile, and has a soft consistency with no obvious focus of infection, the node(s) should be measured (in millimeters) and the patient reevaluated at three- to five-day intervals. Many nodes will regress spontaneously within 2 to 3 weeks without therapy and no further studies will be required. If one or more enlarged nodes persist with increasing size, with or withut tenderness, and palpation reveals hanges in consistency and mobility, further study is warranted. Systemic signs of fever, malaise, and toxicity

often

presents

PPD-T, and Cat-Scratch Skin Tests (January 1967 Through September 1984)
Disorder Neoplasms No. of Negative

Tests Hodgkin disease

lym-

Fig 10. Healthy, asymptomatic 6-year-old with cervical lymphadenitis of 2 weeks duration. She had had no animal scratches but had cat contact during varicella, and she had had many skin and mouth lesions 4 weeks previously. Penicillin and cefaclor therapy were ineffective. Findings from skin tests with PPD-B and PPD-T were negative but skin tests with cat-scratch antigen were positive on two occasions. Adenitis decreased 50% during a 6week period, but persisted unchanged thereafter. Excisional biopsy revealed reactive adenitis and cystic lymphangioma. Patient was well 4 years later.

Non-Hodgkin phoma Lymphosarcoma,

12 0 6 4 2 3 10
2

may necessitate more diagnostic studies and initiation of antibiotic therapy. Specific Diagnosis: Lymphadenopathy Cat-Scratch
diagnosis of

rhabdomyosarcoma Leukemia Tumors Parotid mass Salivary gland Adenitis, cause unknown
Reactive hyperplasia

Chronic The clinical

disease is

Disease.
cat-scratch

Cysts
Cystic hygroma

Thyroid Branchial cleft Thyroglossal duct Submandibular Miscellaneous Sarcoidosis

Histocytosis X

2 3 2 3 4 0 2 2 57

Granulomatous disease, undetermined etiology Neurofibroma, brachial plexus

Total

made when three of the following four criteria are met: (1 ) contact with cat(s), presence of a scratch or a primary denmal or ocular lesion; (2) a positive finding on cat-scratch disease skin test (Antigen is available from the author upon written request.); (3) negative laboratory study (Fig 9) results for other causes of lymphadenopathy; (4) characteristic histopathobogic features in a lymph node biopsy specimen. Recently, studies have shown that the diagnosis of cat-scratch disease is supported by the demonstration of small pleomorphic bacilli in lymph nodes by
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Cervical

Adenitis

TABLE
Different
Etiology

7.

Infectious

Lymphadenopathy Onset
Node Distribution

in Children
Fever-Toxicity

and

Adolescents:
Hemogram

Differentiating
Diagnosis

Features

in Ten
Suppuration

Diseases

of
Treatment

Etiologies Abrupt,
2-3 d

S
aspira-

Streptococcus,
group A Staphylococcus aureus

Regional Regional
Regional

Mild-marked Modmarked Mild-mod

Leukocytosis Leukocytosis
Usually normal,

Aspiration
ture

and cul-

Frequent

Penicillin,

Abrupt,

Aspiration
ture Cat-scratch

and culskin

Frequent
14%

tion Keflex, aspiration,

dicloxacillin, l&D Reassure, aspi-

2-3 d
ba3-10 d

Cat-scratch cillus

mm leukocytosis

test, Gram-nagative bacteria

skin/node
Mycobacterium tuberculosis 2-7 wk Regional Usually Usually normal PPDT >1 5 mm 52%

rate for pain, save pus to make skin test

material INH, RMP, 1 yr Excision if no re-

absent 2-7 wk
Regional Usually Usually normal PPD-T 0-14 mm 74%

sponse Nontuberculous mycobacterial disease Infectious mononucleosis

Excisional (rarely 1 -2 wk biopsy effective)

absent Gen ant and post cervical

Mild-mod Lymphocytosis, atypical Monospot test, Epstein-Barr viNo

INH and RMP Bed rest, symptomatic

Cytomegalovirus Tularemia Brucellosis Toxoplasmosis

1-2 wk 1-7 d

Gen ant and post cervical Regional, 75% ulceroglandular

Generalized

Mild-mod Mod

lymphs >15% Lymphocytosis, atypical Iymphs

Leukocytosis

rus titers Virus isolation, F titer

History and febnle agglutination

No

Reassure, careful follow-up

Streptomycin for 6 d Tetracycline IM

Frequent

1 -7 wk, several

Mod-

marked Cervical ant and post

generalized

Leukopenia, relative lym-

Blood culture,
glut. Brucella
abortus

ag-

No

for 21

d No Reassurance,
pyrimethamine, SDZ I & D, incision and drainage; post, posterior;

mo 1-7 wk

Mild-marked

phocytosis Lymphocytosis, atypical Iymphs

IFA 1gM > 1 : 1 000 fixation; gen, generally;

if ill,

Abbreviations

used are: agglut, agglutination

test; ant, anterior; Iymphs,

CF. complement

IFA, indirect fluorescent antibody; SDZ, sulfadiazine; RMP, nfampin.

IM, intramuscularly;

lymphocytes;

INH, isoniazid;

mm, minimal; mod, moderate;

Warthin-Stanry stain, as well as in the primary skin lesion at the inoculation site (Fig 3). We do not advocate a
skin on lymph node biopsy in the pa-

et al have a thorough

clearly shown the medical evaluation

need for before

resorting

to excisional

biopsy,

which
and anti-

tient with typical cat-scratch disease if the skin test antigen is available. The skin test is safe, reliable, and highly specific; it can be done by the primary care physician to confirm the diagnosis, whereas punch biopsy of the inoculation site is not a routine office procedure. In a baffling, atypicab case of suspected cat-scratch disease, node biopsy should be done by an experienced surgeon, the specimen handled properly, and the results interpreted by a pathologist who is familiar with the special stains needed to detect the cat-scratch disease bacillus. Although cat-scratch skin-test antigen is not easily available, the value of skin testing for those patients who had cat contact on scratch prior to biopsy has been emphasized by Knight et al and Harris et al. Knight
PIR 20 pediatrics in review
#{149}

is often nondiagnostic. Pending results of laboratory tuberculin skin tests, empiric

ent to underlying tissue. The node frequently is detected by the parent; it enlarges rapidly and then remains the same size for weeks or months.

As the infection

continues,

the oven-

biotic

therapy

is often

started,

partic-

ularly if there is a focus such as pharyngitis, conjunctivitis, or skin or pen-

lying skin may become pink to punplish and thin. In 10% to 20% of patients, an abscess with a sinus tract develops spontaneously (Table

odontal aureus

infection.

Adenitis

due

to S

4). Drainage

from

the

tract

is inter-

or fl-hemolytic streptococcus usually resolves with therapy; the adenitis of cat-scratch disease rarely, if

ever, responds.
majority

In my experience,
with antibiotics cat-scratch

the treated

of patients

disease
with one

had been
to four

previously

without

improvement.
Tubercubous Lymphadenitis. The child with nontubercubous mycobac-

tenial or M tuberculosis enitis is usually clinically

an enlarged vical node ( which

cervical adwell, but with

nontender

1 to 3 cm)

or only minimally

tend,er

anterior

ceradher-

is somewhat

mittent, purulent and rarely bloody; occasionally caseous material is discharged. The overlying skin usually does not exhibit increased warmth, even with associated intense erythema (Fig 7). Incision and drainage is not recommended because ulceration and chronic sinus tract drainage frequently complicate this procedure (Fig 8). In a recent study, a diagnosis of mycobactenial adenitis was con firmed in 1 65 patients by: (1) a posi tive PPD skin test and mycobactenial isolate in 72 patients (44%); (2) neg-

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INFECTIOUS

DISEASE

.p

ative cultures for acid-fast bacilli with ositive PPD-Battey and PPD-T tests and compatible histopathobogy or presence of acid-fast bacilli on lymph node section, or both, in 63 patients (38%); (3) positive PPD-Battey and T tests with or without histopathobogic confirmation in 30 patients (1 8%), all of whom had clinical features consistent with the diagnosis of mycobacterial adenitis on 1 - to more than 5-year follow-up. Many of these patients failed to respond to antitubercubous therapy, indicating a diagnosis of dual (PPD-Battey, Gauss, fortuitum, kansasii, and PPDT) Mantoux tests discriminated between M tuberculosis (TB) and nontubercubous mycobactenial adenitis in of nontubercubous enitis. The use mycobactenial ad-

tests

one

to

several

months

later

1 51 of 1 53 patients (99%); dual (PPDBattey/B/PPD-T) tests differentiated between nontubercubosis mycobactenial adenitis and tubercubous adenitis in 1 35 of 1 53 patients (88%). A

PPD-T reaction of 1 to 1 4 mm suggested either a nontuberculous mycobactenial or tubercubous infection, whereas a PPD-T of 1 5 mm or neater was strongly associated with ubercubous disease (Table 8). The nontubercubous mycobacterial-PPD antigens were obtained from Centers for Disease Control [Atlanta] or Connaught Lab, Ltd [Wilbowdale, Canada] for our research and are not otherwise available at present. An old tuberculin (OT) tine on preferably a Mono-Vacc test to avoid false-negative reactions is necommended on the initial examination. In the patient with a positive ( 2 mm) OT test and lack of response to antibiotics, dual Mantoux PPD tests using PPD-T and PPD-Battey antigens would be indicated. If PPD-Battey is not available, but a Tine reaction is
positive with a PPD-T reaction mycobactenial of 0 to

culture findings positive for mycobactenia. When PPD-B and T tests were repeated, the PPD-T induration averaged an 1 8-mm increase; simultaneous PPDnontubercubous mycobacteniab reac-

showed more homologous in 1 7 of our patients with

reactions

tions showed a decrease in indunation in four patients with M tuberculosis infection. The reverse was found for 1 3 patients with a nontubercubous mycobactenial infection. Skin testing (PPD-T or a screening OT test) of
family members or other close con-

to-severe adenitis is directed against the most common infecting agents, S aureus and group A 1-hemolytic streptococci. After cultures (skin, throat, and node aspirate) are done, cboxacilbin, 50 mg/kg/d given orally, or dicboxaciblin, 25 mg/kg/d given orally, is prescribed. Alternatively, one of the cephabosponins given orally, such as cefalexin or cephradine, 50 mg/kg/d, may be prescribed. For the child with severe adenitis and/or ceblulitis and/or who does not tolerate

tacts should be done; 55% and 21 % of family PPD-T tests had positive results in our patients with tubercubus and nontubercubous mycobactenial adenitis, respectively. Other helpful clues in confirming tubercubus adenitis are: history of contact
with a tubencubous person, abnormal

findings on chest roentgenognam, and PPD-T reaction that becomes more positive on two repeated tests than the PPD-nontubercubous mycobacterial reaction had been (Table 8). MANAGEMENT Acute Adenitis

oral therapy, intravenous nafcibbin on oxacillin, 1 50 mg/kg/d, or cephabothin, 1 50 mg/kg/d, may be used. Antibiotic therapy should be continued for no less than five days beyond resolution of acute signs and symptoms (usually at least ten days of therapy). For the neonate with cenvicab adenitis, parentenab antibiotic thenapy with oxacillin or nafcillin, 1 50 mg/ kg/d, for ten to 1 4 days constitutes adequate treatment for S aureus or group B streptococci, the usual etiologic organisms. For patients allergic

1 4 mm of induration,
a nontubercubous

the likelihood

of
in-

fection is good (Table 8). Negative PPD-T and OT tine tests would greatly lessen the likelihood of tubercubous adenitis; however, the PPD-T reaction was negative in 22 of our 131 patients (17%) with nontubencubus mycobactenial lymphadenopahy. Timing of the test relative to the onset and duration of the disease is important: repeat PPD-B and PPD-T

Generally, children with acute cenvical adenitis appear well but complain intermittently of malaise and bocabized neck pain referable to the tender node. Close observation over a few days is usually the appropriate
initial management. Analgesics and/

to penicillin, erythromycin succinate, 40 mg/kg/d, or clindamycin, 30 mg/ kg/d, is prescribed orally. For the child with a periodontal abscess, dindamycin or penicillin V, 50 mg/kg/d, for a ten-day period will usually suffice. Standard textbooks should be

consulted for therapy of unusual infections such as tubanemia, Gramnegative bacilli, Pasteurella multocida, plague, rat-bite fever, and Nocardia. If the response to parenteral
antibiotic therapy is good, after a few

or warm local compresses every four hours may be helpful. Initial antibiotic therapy for the child with moderatepediatrics

days the remainder of the course be completed by the oral route.

#{149}

may

in review

vol. 7 no. 1 july 1985

PIR

21

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Cervical

Adenitis

tend cultures for five to seven days to allow isolation of P multocida or Nocardia species. CHRONIC LYMPHADENITIS

bercubous

mycobactenial

cervical

ad-

enitis,
with

complete excisional removal of the obviously,

is recommended and without complication

biopsy largest
was in

node(s) successful

Cat-Scratch Disease. The most important aspect of the management of chronic cervical adenitis is serial observation for signs of resolution or progression. Infrequently, a patient
Fig 1 1. Child with submandibular cat-scratch disease adenitis unresponsive to five antibacterial agents (erythromycin, trimethoprim-sulfamethoxazole, nafcillin, cloxacillin, and vancomycin) during 6 weeks of therapy. This 8year-old child had facial cat-scratches and two primary inoculation skin papules on his cheek for 4 weeks. Results of PPD-B and PPD-T tests were negative. Findings on two cat-scratch antigen skin tests were positive (30 mm). Chronic seropurulent drainage persisted for 4 months following incision and drainage of sterile pus. Adenopathy gradually resolved after 1 year. with

cat-scratch

disease

will

appear

1 1 1 of our 1 52 patients (86%) (Table 9). After excision of the presenting mass, the adjacent adenopathy will subside spontaneously over 3 to 12 months. Antitubercubous therapy is usually not effective for nontubercubus mycobactenial adenitis; 30 of 30
nontubercubous mycobactenial iso-

acutely

ill with lymphadenitis. In this situation, 1 to 2 weeks of antistaphybococcal and antistreptococcal therapy is advisable. In most patients, cat-scratch disease is managed best
by repeated observation over several

months, usually 2 to 6 months, during which spontaneous involution of the lymphadenopathy will occur. In the relatively healthy child or adolescent
with

typical

cat-scratch

disease Warm,

who

bates (1 00%) were resistant to isoniazid (INH) and 24 (79%) were resistant to nifampin. For the patient who has positive findings on PPD-T skin test with induration greater than 15 mm, particularly if PPD-Battey antigen is unavailable, isoniazid, 10 mg/ kg/d, and nifampin, 1 5 to 20 mg/kg/ d, are recommended for 1 2 months. These medications may be given as
a single dose daily; maximum dose of nifampin is 600 mg and isoniazid

does If clinical improvement is minimal or the cervical swelling continues to increase, reassessment is necessary and surgical consultation may be indicated. Aspiration of the lymph node may be attempted with or without ultrasonography. However, the latter may help localize the site of an abscess and direct placement of the needle. Initially, aspiration is preferred to incision and drainage, since, in a patient with a mycobactenial infection or cat-scratch disease, incision and drainage is frequently followed by devebopment of cutaneous fistulae which may drain for weeks or months (Fig 1 1). On the other hand, the patient whose cervical adenitis is due to S aureus may require incision and drainage to promote healing. Once signs of inflammation have resolved, continued antimicrobial therapy is of little value. Spontaneous regression of residual swelling usually occurs oven several weeks in most patients. If adenitis recurs, ultrasonognaphy for a missed abscess should be considered, and a careful search should be made for a primary source of bacterial infection such as dermatitis, a foreign body, or periodontal abscess. Anaerobic bacteria should respond to penicillin G or dlindamycin. When a history of cat on dog bite is elicited, or if a cervicofacial infection does not respond to standard therapy, the laboratory should be alerted to exPIR 22 pediatrics in review
#{149}

not

seem

ill, antibiotic

therapy
moist

is not

recommended.

compresses applied four to six times daily to the area of cervical swelling and also to the primary inoculation site may hasten involution. In patients
with the ocuboglandubar syndrome of

500 mg. If atypical mycobactenia are isolated, medication can be discontinued. In rare circumstances, in the
child with nontubercubous mycobac-

Paninaud, removal of the ocular granuboma appears to hasten involution of the regional preaunicular lymphadenopathy. Histopathobogic examination of the ocular primary inoculation lesion may reveal a granubomatous conjunctivitis. A positive WarthinStarry silver stain, which reveals pleomonphic cat-scratch bacilli in the granuboma, provides confirmation of the diagnosis of cat-scratch disease. If an abscess develops, repeated needle aspiration is effective. The prognosis is excellent for cervical adenitis due to cat-scratch disease, as complications or sequelae are rare in typical cases. One episode confers lifelong immunity. If the lymph node enlargement is massive (> 5 cm), some degree of lymphadenopathy may persist for 1 to 2 years. Until such time as the cat-scratch bacillus can be grown out in culture or until a better and more available diagnostic test (serologic, skin test) for catscratch disease is made available, close follow-up, at 1- to 2-month intervals, should be carried out to rule out other causes of the adenopathy. Nontuberculous Mycobacterial Adenitis. For the patient with nontu-

terial adenitis in whom surgery is no possible or acceptable, rifampin an INH therapy may be instituted. Isobation of these patients is not necessary

unless large amounts of caseous matenial are being discharged from the
lesions. These children should not be

labeled tubercubous. Careful followup, with repeat PPD testing in 1 to 2 years and chest roentgenognams, if
clinically indicated, are recom-

mended. In our series, the prognosis following surgery was excellent; only two of 1 29 patients developed recurrence of adenopathy. Of 23 patients
without excision of the involved

nodes, 2/1 3 received antitubercubous therapy and 9/1 0 had antitubercubous therapy and incisional biopsy on drainage; suppunation with sinus formation and local drainage on persistent lymphadenopathy for 6 months to 5 years was common (Table 9). Tubercubous Adenitis. If lymph node cultures reveal M tuberculosis, INH and nifampin therapy is the treatment of choice; the outcome is exceblent. usually Both agents should be contin-

ued for 1 2 months.

is unnecessary.

Surgical
When

therapy
infec

tion with M tuberculosis is not localized (noted in 20% of patients), and

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INFECTIOUS

DISEASE

is pulmonary and/or hilar lymph involvement, or if the local disease is extensive, additional antitubercubous therapy such as streptomycin, 20 to 40 mg/kg/d is recommended. The maximum daily dose of streptomycin should not exceed 1 g and the course should probably be limited to 4 to 6 weeks. Response to dual or triple therapy is usually excellent, with marked regression of nodes within 2 to 3 months. Smaller nodes may remain palpable for many months. Following incision and drainage, sinuses usually heal within 2 to 6 months but the condition may persist longer. Because patient compliance is still a major problem in the control of tuberculosis, short-term bimonthly follow-up and long-term fobbow-up are essential to assess theniode apeutic response and to maintain

there

TABLE 9. Management and Outcome for 1 52 Patients with Chronic Lymphadenopathy Due to Nontubercubous (Atypical) Mycobactena (January 1967 through September 1984)
Patients Management Aspiration and/or drainage, mciNo. (%) 1 Ot (6.5) Outcome No. (%) Suppuration and sinus tion (2-1 8 mo) Local drainage forma10(100) Patients

sional biopsy
No surgery or anti13 (8.5) (2-1 2 mo) 2 (15)

tubercubous
apy

therPersistent bymphadenopathy
adenopa-

9 (70)
2 (15)

(6 mo to 5 yr) No follow-up (1)/no thy at 3 mo (1)

Surgical

excision

129

(85.0)

Excellent Local drainage 1-2 mo Local drainage >2-6 mo Facial nerve paresis, transient Died (disseminated disease)
category. chemotherapy; without effect.
with

1 1 1 (86) 5 (4) 7 (5) 5 (4) 1 (1) poor or no poor or no

compliance. Indications for Biopsy. For the patient whose cervical adenopathy persists on increases in size during several on more weeks, excisional biopsy may be indicated. Factors that might indicate early consideration of a bipsy after 1 to 2 months of observation are the following: (1 ) age of the child, particularly if more than 10 years; (2) presence of persistent unexplained fever and/or weight loss, particularly if accompanied by generalized adenopathy, hepatosplenomegaly, and/or an exanthem; (3) fixation of the lymph node to the overlying skin and/or underlying tissue; (4) supradlavicular location of the adenopathy; (5) absence of local tenderness; and (6) increasing size of the node. The palpable margins of the enlarged node should be outlined with ink marks and node size measured carefully with a ruler in the bongest dimension and at right angles. Prior to biopsy, a few laboratory tests bear repetition such as CBC, sedimentation rate, Mono-Vacc on PPD tests, and appropriate serologic tests (Table 7). A repeat differential WBC count may reveal atypical cells, suggesting a viral infection. A decrease in hemoglobin on hematocnit level compared with values in the mitial study may suggest a systemic . fection, a blood dyscrasia, or maligandy. An abnormal corrected sedimentation rate would suggest an infectious disease. Serologic testing for

Percent

of patients patients
and three

in each
responded.

management

t Nine
response

received

antitubercubous 3 to 6 months
antituberculous

six had

:1:Two patients, INH therapy, Forty-one patients received

response.

chemotherapy

Epstein-Barn virus, cytomegalovirus, on toxoplasmosis might be indicated. Repeat Mono-Vacc and/or PPD-T tests, if negative, would rule out tubencubous disease. A chest roentgenogram might reveal hilar or mediastinal adenopathy and rube out pulmo-

nary disease. Ultrasonography of the mass to rube out a cyst should be considered. Transillumination of the mass should always be done to rule out a cyst or to direct needle aspiration of an abscess. Knight and Reiner reviewed the problem of superficial lumps in children and, based upon the histologic diagnosis of 775 superficial masses excised, concluded that of the 12 children (1 .5%) with malignant lesions
in their study, four fifths could be

childs superficial lump. Two lesions, squamous epithelial cysts and pibomatnixomas, accounted for nearby 70% of the excised superficial lumps in the series of Knight and Reiner. However, in the same group of children, neoplastic diseases were found in 31 of 239 children (1 3%) who underwent peripheral node biopsy. Thus, careful follow-up is essential, with appropniate studies (Fig 9) for a 1 - to 2-month period to decide whether excisional biopsy is necessary. The cost and morbidity of lymph node biopsy must be considered inasmuch as 52% of the nodes removed in this series reveabed only nondiagnostic reactive hyperplasia. The major reasons for
diagnostic failure in biopsy of lymph

recognized on the basis of five risk factors: (1 ) onset in the neonatal penod; (2) a history of rapid on progressive growth; (3) skin ulceration; (4) fixation to or location beneath the fascia; and (5) a firm mass greater than 3 cm in diameter. In the absenpe of any of these risk factors, parents can be reassured at the initial consultation with a 99% accuracy of the presumably benign nature of their
pediatrics in

nodes Mann.

are reviewed

by Bednose

and

CONCLUSIONS In children,
is commonly

acute
due

cervical
to a viral

adenitis
infection

with spontaneous recovery in 1 to 2 weeks. Less often, S aureus, group A f3-hemolytic streptococci, or other bacteria, can cause severe adenitis with systemic toxicity requiring anti#{149}

review

vol. 7 no. 1 july 1985

PIR 23

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Cervical

Adenitis

bacterial therapy for ten to 1 4 days. In most patients, a detailed history, physical examination, a complete blood count and differential, and selected bacterial cultures (throat, node, or cyst aspirate) will guide management. Chronic lymphadenitis, observed less often in children and adolescents, is mainly due to a bacterial (cat-scratch disease), a mycobactenab, or rarely to a fungal on parasitic infection. Assessment with repeated examinations, appropriate serologic and/or skin tests (Mono-Vacc, PPDB and T, cat-scratch), and cultures, willusually provide an etiobogic diagnosis, so that symptomatic management on specific antibiotic therapy can be appropriately prescribed.
ACKNOWLEDGMENTS Table 7 was provided by James

SUGGESTED

READING

Lampe AM, Baker GJ, Septimus EJ, et al: Cervicofacial nocardiosis in children. J Pediatr 1981 99:593 Marcy SM: Infections head and neck. 1 983;2:397 of lymph Pediatr nodes of the Infect Dis

Baehner AL: Neutrophil dysfunction associated with states of chronic and recurrent infection. Pediatr Clin North Am 1980;27:377

Baker CJ: Group B streptococcal

enitis in infants. Am J

cellulitis-adDis Child

1982;1 36:631
Bedrose AA, Mann JP: Lymphadenopathy in children. Adv Pediatr 198128:341 Brook I: Aerobic and anaerobic bacteriology of cervical adenitis in children. Clin Pediatr 1980:19:693 Carithers HA: Cat-scratch skin test antigen: Purification by heating. Pediatrics

Margileth AM, Chandra A, Altman AP: Chronic lymphadenopathy due to mycobacterial infection: Clinical features, diagnosis, histopathology and management. Am J Dis Child

1984;138:91

1977;60:928
Harris BH, Webb HW, Wilkinson AH Jr, et al: Mycobacterial lymphadenitis. J Pediatr Surg 1982;1 7:589-590 Knight PJ, Hamoudi AB, Vassy LE: The diagnosis and treatment of midline neck masses in children. Surgery 1983;93:603 Knight PJ, Mulne AF, Vassy LE: When is lymph node biopsy indicated in children with enlarged peripheral nodes? Pediatrics 1982;69:391 Knight PJ, Aeiner GB: Superficial lumps in children: What, when, and why? Pediatrics 1983;72:147

Margileth AM, Zawadsky PM: Chronic lymphadenopathy in children and adolescents. Am Fam Physician, May 1985 Margileth AM, Wear DJ, Hadfield TL, et al: Catscratch disease: Bacteria in skin at the primary inoculation site. JAMA 1 984;252:928 Wear DJ, Malaty RH, Zimmerman LE, et al: dat-scratch disease bacilli in conjunctiva of patients with Parinauds oculoglandular syndrome. Ophthalmology, in press 1985 Zitelli BJ: Neck masses in children: Adenopathy and malignant disease. Pediatr Clin North Am 1981 28:813

w. Bass,

MD.

Vaginitis

and Dysuria

Dysuria in Adolescent Girls: Urinary Tract Infection or Vaginitis? Demetriou E, et al. Pediatrics 1982;70:299. Vulvovaginitis in Premenarcheal Girls: Clinical Features and Diagnostic Evalu tion. Paradise JE, et al. Pediatrics 1982;70:1 93. Fifty-three adolescent girls who were initially seen with dysuria were studied to determine the cause of their complaint: 41 % of patients were found to have vaginitis, 1 7% had urinary tract infections of bacterial etiology, and another 1 7% had both urinary tract infection and vaginitis. The diagnosis of acute urethral syndrome of uncertain etiology was made in an additional 8% of patients. Four percent had nonspecific vulvitis and 2% had clinical herpes simplex infection. As had been demonstrated previously in adults, a history of external dysuria (pain felt as the urine passes over inflamed vaginal labia) associated with vaginal discharge or irritation was highly predictive of vaginitis or vulvitis; urine culture is not necessary in these patients
initially.

The diagnosis
patients infection urinary

of urinary

tract

infection

was

less

easily

predicted.

Even

in those

with a symptom complex thought to be highly (dysuria and frequency without vaginal discharge tract infection alone and another 27% had urinary

suggestive of urinary tract or irritation), only 33% had tract infection and vaginitis.

The presence of internal dysuria was less useful in predicting adolescents than had been found in adults. Pyuria (>5 WBC
similarly not helpful, as it was seen not only with urinary

urinary tract per high-power

infection but

infection in field) was

also with

tract

trichomonal,

chlamydial,

and gonococcal

infections.

Comment: Dysuria is a common presenting complaint among female adolescents: in the majority of cases the cause is a gynecologic infection. More than 1 0% of premenarcheal girls with suspected vaginitis also are initially seen with dysuria as their
chief complaint. The initial evaluation of such patients, in addition to a careful history

and physical examination (including questions regarding perineal hygiene and a pelvic examination in sexually experienced patients) should include microscopic examination of vaginal secretions for Trichomonas and Candida (and helminth ova in younger patients), vaginal culture for Candida, endocervical culture for Neisseria gonorrhoeae
when possible, and urine culture in those in whom vaginitis or vulvitis is not strongly

suspected. Urinalysis is not particularly helpful and should probably be reserved for those patients in whom a diagnosis has not been established after initial gynecobogi assessment and urine culture. In this situation, the finding of pyuria may sugges
infection with Chiamydia trachomatis or urinary tract infection with less than 10

organisms PIR 24 pediatrics in review

#{149}

per milliliter.

(S. Mautone,

NJ Medical

School)

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Cervical Adenitis Andrew M. Margileth Pediatrics in Review 1985;7;13 DOI: 10.1542/pir.7-1-13

Updated Information & Services Permissions & Licensing

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tenial polyvalent immune globulin by immunization of adult volunteers with pneumococcal, meningococcal A and C, and H influenzae-PRP vaccines. The globulin is prepared by an ethanol precipitation technique from plasma obtained from adult volunteens by plasmapheresis. It has been suggested that such a preparation may have potential prophylactic value in high-risk infants less than 2 years of age, such as those with sickle cell disease, children with immunodeficiency on even in selected population groups in which the incidence of H influenzae disease is particularly high (American Indian on Eskimo populations).
SUGGESTED
Band

READING
DW, Ajello G: Prevention of

JD, Fraser

Hemophilus influenzae type b disease. JAMA 1 984;251 :2381-2386 Cochi SL, Broome CV, Hightower AW: Immunization of US children with Hemophilus influenzae type . b polysaccharide vaccine. JAMA 1 985;23:521 -529 Feigin RD, Baker CJ, Herwaldt LA, et al: Epidemic meningococcal disease in an elementary school classroom. N EngI J Med 1 982;307:1 255-1257 Gold R, Lepow ML, Goldschneider TF, et al: Kinetics of antibody production to group A and group C meningococcal polysaccharide vaccines administered during the first six years of life: Prospects for routine immunization of infants and children. J Infect Dis 1979;140:690-697 Granoff DM, Daum RS: Spread of Haemophilus influenzae type b: Recent epidemiologic and therapeutic considerations. J Pediatr 1980;97:854-860 Granoff DM, Squires JE, Munson RS, et al: Siblings of patients with Haemophilus meningitis have impaired anticapsular antibody responses to Haemophilus vaccine. J Pediatr

1983;103:1 85-1 91 Meningococcal Disease Surveillance Group, 1 974: Meningococcal disease secondary attack rate and chemoprophylaxis in the United States, 1974. JAMA 1 976;235:261 265 Munford RS, de E Tauney A, Souza DE, et al: Spread of meningococcal infections within households. Lancet 1974:1 :1275-1 278 National Institute of Allergy and Infectious Diseases: Summary of a workshop on Haemophilus influenzae type b vaccines. J Infect Dis 1983:148:167-175 Peltola H, Kayhty H, Virtanen M, et al: Prevention of Hemophilus influenzae type b bacteremia infections with the capsular polysaccharide vaccine. N EngI J Med 1984;310:1561 -1566 Ward JI, Fraser DW, Baraff II, et al: Haemophilus influenzae meningitis: A national study of secondary spread in household contacts. N EngI J Med 1979;301 :122-1 26

Department

of Corrections

In Dr Margileths article, Cervical Adenitis, which appeared in the July 1985 issue (PIA 1985;7:13-24), in the third line from the bottom of Table 8 on page 21, NTMTPD skin tests should read PPD-T skin tests.

Self-Evaluation Continued from page

12. A 4-year-old
95

oped

I 1. Which one of the following statements pertaining to meningococcal disease is not true? A. Contacts of patients with meningococcal disease should have nasopharyngeal cultures.

B. The risk of acquiring menindisease is significantly greater after exposure to a patient with the disease than after exposure to a carrier. C. Occurrence of secondary cases in the family is much less likely if the index patient is an adult rather than an infant. D. If the organism is sensitive, sulfadiazine is the drug of choice for prophylaxis. E. Contacts of patients with meningococcal disease should seek immediate medical attention for any febrile illness, even if they are using rifampin prophylaxis.

gococcal

cemia. should laxis? A. Only children 4 years of age or younger in his household. B. All household members. c. Day care contacts. D. All medical personnel involved in his care. E. The patient himself, despite parenteral penicillin treatment. 13. The single most effective antibiotic for the eradication of nasopharyngeal carriage of Haemophilus influenzae type b is: A. Ampicillin. B. Cefaclor. C. Rifampin. D. Erythromycin-sulfisoxazole. E. Trimethoprim-sulfamethoxazole.

boy has develmeningococcal septiWhich of his contacts receive antibiotic prophy-

14. Antibiotic prophylaxis is recommended for which of the following contacts of a child with invasive H influenzae type b dis-

ease?
A. All household contacts, even if there are no other children 4 years of age or younger. B. All household contacts, if there are other children 4 years of age or younger. C. Only household contacts who are 4 years of age or younger. D. Pregnant women. E. Nursery school contacts if two cases of invasive disease have occurred within 60 days.

15. True statements about the5 currently available H influenzae type b vaccine include: A. Infants between 3 and 17 months of age receive little protection from the vaccine. B. It is recommended for all children between 2 and 5 years of age. C. It is recommended for infants at 18 months of age if they are at increased risk. D. It is a safe vaccine. E. If all children of the appropriate age group received the vaccine, the incidence of the disease in all age groups would be expected to decline dramatically.

S
PIR 94 pediatrics in review
#{149}

vol. 7 no. 3 september

1985

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