Lymphadenopathy

Background

Lymphadenopathy is common and usually benign in the ED setting
Normal lymph nodes are typically <1 cm; supraclavicular, popliteal, and iliac nodes >0.5 cm are considered abnormal
Most ED presentations are reactive lymphadenopathy from regional infection
Key EM concern is identifying malignancy or serious infection requiring urgent intervention

Location helps narrow differential:
- Cervical — URI, pharyngitis, dental infection, mononucleosis, lymphoma, head/neck malignancy
- Supraclavicular — high suspicion for malignancy (left: abdominal malignancy via Virchow node; right: mediastinal/lung pathology)
- Axillary — upper extremity infection, cat scratch disease, breast cancer, lymphoma
- Inguinal — STIs, lower extremity infection, lymphoma, pelvic malignancy
- Generalized — viral (HIV, EBV, CMV), autoimmune (SLE), lymphoma, leukemia, medications
Characteristics:
- Tender, warm, mobile → reactive/infectious
- Hard, fixed, nontender → concerning for malignancy
- Matted nodes → granulomatous disease (TB, sarcoid) or lymphoma
- Rapidly enlarging → infection or aggressive malignancy

Evaluation of Lymphadenopathy

Most localized lymphadenopathy in young patients with obvious infectious source needs no workup
Consider workup when:
- Duration >4-6 weeks without improvement
- Supraclavicular location
- Node >2 cm without obvious infectious cause
- Associated constitutional symptoms (weight loss, night sweats, fever)
- Hard, fixed, or rapidly growing
Labs (as indicated): CBC with differential, peripheral smear, ESR/CRP, LDH, uric acid, mono spot, HIV
Imaging: CT with contrast if deep space infection or malignancy suspected; ultrasound to characterize superficial nodes
Biopsy: Not typically performed in the ED; refer for excisional biopsy if malignancy suspected (avoid FNA alone for suspected lymphoma)

Treat the underlying cause
If reactive from regional infection → treat the infection; lymphadenopathy should resolve over weeks
If abscess suspected within node → I&D or aspiration
If malignancy suspected → urgent outpatient referral for biopsy

Most patients with lymphadenopathy are discharged from the ED
Admit if: associated sepsis, deep space infection requiring IV antibiotics, or airway compromise from cervical lymphadenopathy
Urgent referral for: supraclavicular nodes, nodes >2 cm persistent >4 weeks, suspicion for malignancy

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