1. History and examination to look for obvious causes or worrisome features* |
2. Refer children with worrisome features for early biopsy¶ |
3. Evaluate and treat causes that appear obvious based on initial evaluation |
4. When the cause remains uncertain after the initial evaluation: |
- Lymph node ≥2 cm (0.8 inches) in longest diameter:
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a. Obtain CBC/differential, ESR/CRP, LDH, CXR - Worrisome features*: Proceed to biopsy¶
- No worrisome features*:
- Signs of infection in lymph node or distal to lymph node:
- Obtain cultures and other microbiologic studies as indicatedΔ
- Provide 10 to 14 day trial of antibiotic therapy, broadened as indicated◊
- No signs of infection:
- Observe for two to three weeks
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b. Response to antibiotic therapy/broadened antibiotic therapyΔ or observation - Regression in size: No additional evaluation or therapy
- No regression or increase: Biopsy¶
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- Lymph node <2 cm (0.8 inches) in longest diameter:
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a. Initial management according to symptoms/signs of infection within or distal to node: - Symptoms or signs of infection:
- Obtain cultures and other microbiologic studies as indicatedΔ
- Initiate a 10 to 14 day trial of antibiotic therapy, broadened as indicated◊
- No symptoms or signs of infection:
- Observe for two to three weeks
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b. Response to antibiotic therapy/broadened antibiotic therapy◊ or observation: - Regression in size: No additional evaluation or therapy
- No regression or increase: Obtain a CBC/differential, perform TST, and initiate or broaden antimicrobial therapy
- CBC/differential concerning for malignancy (eg, lymphoblasts, cytopenias in more than one cell line): Biopsy¶
- TST positive: Additional evaluation as indicated for tuberculosis or nontuberculous mycobacteria
- TST negative and lymphadenopathy regresses in size: No additional evaluation or therapy
- TST negative and lymphadenopathy does not regress in size: Obtain ESR/CRP and serology for EBV, CMV, HIV, and Bartonella henselae (for children with exposure to cats or kittens); evaluate other conditions as indicated by the history and examinationΔ
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5. Obtain biopsy¶ after four weeks if the diagnosis remains uncertain and the lymph node has not regressed in size or there is no response to antimicrobial therapy/broadened antimicrobial therapy |