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Iliac
Enlarged iliac nodes are palpable deeply over the inguinal ligament and become inflamed
with lower extremity infection, urinary tract infection, abdominal trauma, and
appendicitis. Of note, iliac adenitis, which can present with fever, limp, and inability to
fully extend the leg, may mimic the signs and symptoms of septic hip arthritis. Unlike in
hip disease, however, hip motion is not limited on examination. Iliac adenitis may also be
confused with appendicitis, but the pain initially occurs in the thigh and hip rather than in
the periumbilical region or right lower quadrant.

GENERALIZED LYMPHADENOPATHY
Generalized lymphadenopathy, defined as enlargement of lymph nodes in two or more
noncontiguous regions, can be a manifestation of both infectious and noninfectious
systemic illnesses ( Table 47.2 ). Akin to localized lymphadenopathy, generalized
lymphadenopathy in children is most often caused by bacterial or viral infections. As an
example, the high incidence of vomiting and abdominal pain in streptococcal pharyngitis
has been attributed to abdominal lymph node swelling and inflammation, suggesting a
more systemic pattern of adenopathy in streptococcal disease. More rare bacterial causes
of generalized lymphadenopathy include the zoonotic infections brucellosis, leptospirosis,
and tularemia. Brucellosis is acquired by exposure to cattle, sheep, goats, or
unpasteurized milk or cheese and causes systemic symptoms including fever, night
sweats, weight loss, arthralgias, and epididymoorchitis, as well as nonspecific
examination findings including generalized lymphadenopathy and hepatosplenomegaly.
Leptospirosis is most common in tropical climates, acquired via exposure to contaminated
soil or water (particularly during swimming). Clinical manifestations are nonspecific,
including fever, rigors, myalgias, headache, conjunctivitis, rash, hepatosplenomegaly, and
lymphadenopathy. Brucellosis, leptospirosis, and tularemia (discussed previously) should
be considered in the differential diagnosis of a child presenting with systemic symptoms,
particularly fever, and physical examination findings of generalized lymphadenopathy if
the appropriate exposure history is elicited.
Common viral causes of generalized adenopathy include EBV or CMV mononucleosis,
and rubella and measles infections in parts of the world where these diseases are endemic.

Though EBV mononucleosis classically causes fever, pharyngitis, and anterior and
posterior cervical adenopathy; axillary and inguinal lymphadenopathy may also be
presenting signs. In children with symptoms of infectious mononucleosis but a negative
monospot and/or negative antibody titers to EBV antigens, CMV may be the cause.
Rubella produces a prodrome of low-grade fever and lymphadenopathy (posterior
cervical, postauricular, or generalized) followed by the development and rapid spread of a
pink, maculopapular rash from face to the trunk and extremities. Measles (rubeola)
produces a prodrome of fever, malaise, and anorexia followed by cough, conjunctivitis,
coryza, and characteristic Koplik spots on the buccal mucosa. The exanthem of measles
also has a cranial to caudal progression of a blanching, maculopapular rash, and lesions
can become confluent. Children with severe measles may exhibit generalized