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39 authors, including:
Marco Benazzo
Marco Lucioni
University of Pavia
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Nicola Principi
Giovanni Succo
University of Milan
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Original Research
Development of an algorithm
for the management of
cervical lymphadenopathy in
children: consensus of the
Italian Society of Preventive
and Social Pediatrics, jointly
with the Italian Society of
Pediatric Infectious Diseases
and the Italian Society of
Pediatric
Otorhinolaryngology
Expert Rev. Anti Infect. Ther. Early online, 111 (2015)
Elena Chiappini*1,
Angelo Camaioni2,
Marco Benazzo3,
Andrea Biondi4,
Sergio Bottero5,
Salvatore De Masi6,
Giuseppe Di Mauro7,
Mattia Doria8,
Susanna Esposito9,
Giovanni Felisati10,
Dino Felisati10,
Filippo Festini11,
Renato Maria
Gaini12,13,
Luisa Galli1,
Claudio Gambini14,
Umberto Gianelli15,
Massimo Landi16,
www.tandfonline.com
10.1586/14787210.2015.1096777
Other members of the Italian Guideline Panel for the Management of Cervical Lymphadenopathy in Children
Sabrina Becciani, Caterina Bonaccini, Sofia Delios, Pasquale Di Pietro, Ludovica Facchini, Martina Giacalone, Simona Montano,
Sara Sollai, Paola Piccini, Giulia Remaschi, Daniele Serranti, Alessia Stival, Elisabetta Venturini.
List of scientific societies involved: Italian Society of Preventive and Social Pediatrics, Italian Society of Pediatric Infectious
Diseases, Italian Society of Pediatric Otolaryngology, Italian Society of Otolaryngology, Italian Federation of Family Pediatricians,
Italian Society of Primary Care Pediatrics, Italian Society of Chemotherapy, Italian Association of Clinical Microbiology, Italian
Association of Pediatric Hematology and Oncology, Italian Society of Pathology and Diagnostic Cytopathology, Italian Society
of Pediatric Allergy and Clinical Immunology, Italian Pediatric Nurses Association, Italian Society of Medical Radiology, Parents
Association: We For You.
ISSN 1478-7210
Original Research
Marco Lucioni17,
Nicola Mansi18,
Rachele Mazzantini1,
Paola Marchisio9,
Gian Luigi Marseglia19,
Vito Leonardo
Miniello20,
Marta Nicola21,
Andrea Novelli22,
Marco Paulli23,
Marina Picca24,
Marta Pillon25,
Paolo Pisani26,
Carlotta Pipolo27,
Nicola Principi9,
Iacopo Sardi28,
Giovanni Succo29,
Paolo Tom30,
Enrico Tortoli31,
Filippo Tucci32,
Attilio Varricchio33
and Maurizio
de Martino1 Italian
Guideline Panel for the
Management of Cervical
lymphadenopathy in
Children34
1
Chiappini et al.
clinical scenarios. Situations requiring a watchful waiting strategy, those requiring an empiric
antibiotic therapy, and those necessitating a prompt diagnostic workup, considering the risk for a
severe underling disease, have been identified. Conclusion: The present algorithm is a practice
tool for the management of pediatric cervical lymphadenopathy in the hospital and the ambulatory settings. A multidisciplinary approach is paramount. Further studies are required for its
validation in the clinical field.
KEYWORDS: cervical lymphadenopathy
Introduction
ambulatory settings. The algorithm also underlines the importance of an integrated multidisciplinary approach.
Methods
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Original Research
infectious diseases, immunology, nursing practice, and research methodology, and a member
of the parents association We for You. No
panel member declared any conflict of interest
considering the guideline topics. The panel met
on three occasions, and many of the consultations involved in the document development
took place interactively by e-mail or telephone
contact.
Definitions
Quinidine
Phenytoin
Hydralazine
Penicillin
Primidone
Sulfonamides
Sulindac
Modified from [20,21].
Original Research
Chiappini et al.
Acute lymphadenopathy
Subacute/chronic
lymphadenopathy
Bacterial infections
Bacterial infections
Staphylococcus spp.
Mycobacterium tuberculosis
Streptococcus spp.
nontuberculous mycobacteria
Anaerobic bacteria
Bartonella henselae
Toxoplasma gondii
Borrelia burgdorferi
Brucella spp.
CMV
Viruses
Leishmania spp.
EBV
CMV
Francisella tularensis
EBV
Listeria monocytogenes
Adenovirus
Viruses
Staphylococcus aureus
HIV
Nontuberculous mycobacteria
CMV
Toxoplasma gondii
Mumps virus
EBV
CMV
Other
EBV
Rubella
Measles
Metastasis
Varicella
Sarcoidosis
Other
Toxoplasma gondii
Kawasaki disease
PFAFA
CMV, cytomegalovirus; EBV, EpsteinBarr virus; PFAFA, periodic fever, aphthous
stomatitis, pharyngitis and adenitis; HIV, human immunodeficiency virus.
and central colliquative necrosis with possible subsequent fistulization is a common evolution.[6]
Malignancy may be suspected if lymph nodes are rapidly
enlarging, nontender, and fixed. Cervical lymph node greater
than 2 cm should be considered potentially malignant and this
risk is substantially higher when diameter exceeds 3 cm.[6,22
24] Regardless of size, age >8 years, generalized lymphadenopathy, supraclavicular or lower cervical nodes involvement are
associated with increased risk of malignancy.[6,2224] In a
retrospective study of 175 children, the involvement of the
high, middle, and lower jugular nodes and the posterior triangle
of the neck was significantly associated with an increased risk of
malignancy compared with involvement of submental and submandibular regions (P = 0.001, 95% CI = 5.46 to 25.57).[25]
This finding is also confirmed in an observational study including 120 Indian children.[26] Associated systemic symptoms,
including weight loss, night sweats, unexplained fever, or fatigue, should also be addressed and suggest malignancy or a
chronic inflammatory condition.[2]
According to the Referral for suspected Cancer Guidelines
issued by the National Institute for Health and Clinical
Excellence (NICE), urgent referral is advised if one or more of
4
Age
Aetiology
14 weeks
Staphylococcus aureus
-hemolytic group B Streptococcus pyogenes
112 months
15 years
614 years
Staphylococcus aureus
GARFIELD
Original Research
Original Research
Chiappini et al.
Figure 1. Algorithm for the management of cervical lymphadenopathy in children. LA: lymphadenopathy, CRP: C reactive protein, LDH: lactate dehydrogenase,
EBV: EpsteinBarr virus, TST: tuberculin skin test, IGRA: interferon-gamma release assay.
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Original Research
Original Research
Chiappini et al.
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Original Research
The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or
financial conflict with the subject matter or materials discussed in
the manuscript apart from those disclosed.
Original Research
Chiappini et al.
Key issues
The vast majority of children with cervical lymphadenopathy has with a benign self-limiting condition and cancer occurs at a rate lower
than 1%, but >25% of malignant pediatric cancers involve the head and neck regions.
The present practical algorithm may be followed in order to select children at risk for complex diseases requiring urgent referral to the
oncologist (indicated by the red flags), those requiring laboratory tests, imaging investigations or tissue sampling, and those requiring an
empirical antibiotic therapy or a watchful waiting.
A careful follow-up is recommended in every child, since any lymphadenopathy which does not regress in 46 weeks or incompletely
resolves in 812 weeks should be investigated.
Ultrasonography scan is recommended as a first-level investigation. However, no single ultrasound feature is specific for a benign or a
malignant disease.
Fine needle aspiration biopsy (FNAB) in children is poorly useful, in general, in Western countries, especially in case of suspected
malignancy, due to high proportion of false-negative results.
Excisional biopsy is recommended in the suspicion of cancer or when the first- and second-level investigations did not allow to reach a
final diagnosis.
In nontuberculous mycobacterial lymphadenopathy, when feasible, complete lymph node surgical excision is the most effective
therapeutic option.
References
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