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neoplastic processes. Lymphadenopathy of greater than 3 weeks’ duration is considered
chronic.
The clinician caring for a child with lymphadenopathy will benefit from knowledge of
the anatomic distribution of nodes in the area and their drainage patterns as described in
Figures 47.1 and 47.2 , as well as Table 47.1 . The location of lymphadenopathy is often
suggestive of a possible cause.

CAUSES OF LYMPHADENOPATHY BY REGION
Cervical
Enlargement of cervical lymph nodes is a common presenting sign in a variety of
pediatric illnesses. In order to narrow the differential diagnosis, it is helpful to identify the
time course of swelling (acute or chronic); history or presence of localized infections;
occurrence of systemic symptoms; and specific location, symmetry, and characteristics of
enlarged nodes. Cervical anatomy is complex, however nodes in the region can be
classified generally as either superficial or deep. Superficial cervical nodes, palpated
readily along the anterior and posterior borders of the sternocleidomastoid muscle, drain
the shallow structures of the head and neck—particularly the oropharynx, external ear,
and parotid. In contrast, deep cervical nodes, both superior and inferior, receive lymphatic
drainage from a wider area of underlying structures of the head and neck, including the
nasopharynx, tonsils and adenoids, larynx, and trachea. While there are numerous
infectious and noninfectious causes of acute and chronic cervical lymphadenopathy, the
most common etiologies in children are infectious (see Chapter 94 Infectious Disease
Emergencies ).
By far, the most common cause of acute cervical adenopathy in children is reactive
adenopathy associated with a viral upper respiratory tract infection. Superficial nodes are
generally symmetrically enlarged, mobile, and minimally tender. Reactive adenopathy
may persist for 2 to 3 weeks beyond the resolution of a viral illness. However, there
should be no progression in the size or the extent of the adenopathy after resolution of
symptoms of the virus.
Another common infectious cause of cervical lymph node enlargement, particularly in
preschool-aged children, is lymphadenitis. Lymphadenitis occurs when an enlarged node

becomes inflamed and tender over the course of a few days, as the result of a viral or
bacterial infection. Viral adenitis is often associated with fever, conjunctivitis,
pharyngitis, or other symptoms of an upper respiratory tract infection and causes acute
bilateral swelling. Common causes are rhinovirus, adenovirus, enterovirus, influenza
virus, respiratory syncytial virus, Epstein–Barr virus (EBV), and cytomegalovirus
(CMV). Less commonly, herpes simplex, human herpesvirus type 6 (roseola), or measles,
mumps, or rubella are causative agents. In contrast, bacterial adenitis typically is
unilateral and presents with the rapid onset of a firm, tender, lymph node over 1 to 3 days.
The overlying soft tissue becomes warm, edematous, and erythematous. Fever often
accompanies the infection. If left untreated, the node may become suppurative, which is