Rosen & Barkin's 5-Minute Emergency Medicine Consult (429 page)

• Kawasaki disease
  
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis)
  

TREATMENT

Ensure airway, breathing, and circulation management and hemodynamic stability

• General principles:
  
  • Antibiotics based on involved primary organ/suspected pathogen (see also “Cellulitis”)
    
  • Consider local prevalence of MRSA and other resistant pathogens in addition to usual causes
    
  • Usual outpatient treatment: 7–10 days
    
  • Elevation
    
  • Application of moist heat
    
  • Analgesics
    
• Drainage of abscesses if present:
  
  • Obtain culture if drainage performed, especially to help identify resistant pathogens
    
• Skin origin:
  
  • Outpatient:
    
    • Oral cephalexin plus trimethoprim/sulfamethoxazole (TMP/SMX) (to cover CA-MRSA)
      
    • Alternatives to cephalexin: Oral dicloxacillin, macrolide, or levofloxacin
      
    • Alternatives to TMP/SMX: Clindamycin or doxycycline
      
  • Inpatient:
    
    • IV nafcillin or equivalent, plus IV vancomycin (to cover CA-MRSA)
      
• Pharyngeal or periodontal origin:
  
  • Outpatient:
    
    • Oral penicillin VK
      
    • Alternatives: Oral clindamycin or amoxicillin/clavulanate
      
  • Inpatient:
    
    • IV penicillin G (aqueous) and IV metronidazole
      
    • Alternatives: IV ampicillin/sulbactam or IV clindamycin
      
• Axillary lymphadenitis:
  
  • Outpatient:
    
    • Oral penicillin VK
      
    • Alternatives: Oral macrolide or amoxicillin/clavulanate
      
  • Inpatient:
    
    • IV penicillin G (aqueous)
      
    • Alternatives: IV ampicillin/sulbactam
      
• Acute unilateral cervical suppurative lymphadenitis:
  
  • Outpatient:
    
    • Oral penicillin VK
      
    • Alternatives: Oral clindamycin or amoxicillin/clavulanate
      
• MRSA:
  
  • Nosocomial MRSA:
    
    • IV vancomycin or PO or IV linezolid
      
  • CA-MRSA:
    
    • PO: TMP/SMX, clindamycin or doxycycline
      
    • IV: Vancomycin or clindamycin
      

• Amoxicillin/clavulanate: 500–875 mg (peds: 45 mg/kg/24 h) PO BID or 250–500 mg (peds: 40 mg/kg/24 h) PO TID
  
• Ampicillin/sulbactam: 1.5–3 g (peds: 100–300 mg/kg/24 h up to 40 kg; >40 kg, give adult dose) IV q6h
  
• Cephalexin: 500 mg (peds: 50–100 mg/kg/24 h) PO QID
  
• Clindamycin: 450–900 mg (peds: 20–40 mg/kg/24 h) PO or IV q6h
  
• Dicloxacillin: 125–500 mg (peds: 12.5–25 mg/kg/24 h) PO q6h
  
• Doxycycline: 100 mg PO BID for adults
  
• Erythromycin base: (adult) 250–500 mg PO QID
  
• Linezolid: 600 mg PO or IV q12h (peds: 30 mg/kg/d divided q8h)
  
• Metronidazole: (adult) 15 mg/kg IV once, followed by 7.5 mg/kg IV q6h
  
• Nafcillin: 1–2 g IV q4h (peds: 50–100 mg/kg/24 h divided q6h); max. 12 g/24 h
  
• Penicillin VK: 250–500 mg (peds: 25–50 mg/kg/24 h) PO q6h
  
• Penicillin G (aqueous): 4 mIU (peds: 100,000–400,000 U/kg/24 h) IV q4h
  
• Rifampin: 600 mg PO BID for adults
  
• TMP/SMX: 2 DS tabs PO q12h (peds: 6–10 mg/kg/24 h TMP divided q12h)
  
• Vancomycin: 1 g IV q12h (peds: 10 mg/kg IV q6h, dosing adjustments required age <5 yr); check serum levels
  

FOLLOW-UP

• Toxic appearing
  
• History of immune suppression
  
• Concurrent chronic medical illnesses
  
• Unable to take oral medications
  
• Unreliable patients
  

• Mild infection in a nontoxic-appearing patient
  
• Able to take oral antibiotics
  
• No history of immune suppression or concurrent medical problems
  
• Has adequate follow-up within 24–48 hr
  

• If not found in context of acute infection and not quick to resolve with course of antibiotics, evaluate for more serious underlying causes (e.g., malignancy)
  
• Lymph node biopsy may be helpful in the following circumstances:
  
  • Clinical findings indicate likely malignancy
    
  • Lymph node size >1 cm
    
  • Supraclavicular location
    

• Follow-up within 24–48 hr for response to treatment
  
• If symptoms worsen—including new or worsening lymphangitis, new or increasing area of redness over the node, worsening fever—patient should be instructed to return sooner
  

• Staph species are the most common cause of acute regional lymphadenitis due to pyogenic bacteria
  
• Empiric antibiotic coverage must extend to include CA-MRSA, in addition to coverage for other staph species and strep
  

• Abrahamian FM, Talan DA, Moran GJ. Management of skin and soft-tissue infections in the emergency department.
  Infect Dis Clin North Am
  . 2008;22:89–116.
  
• Boyce JM. Severe streptococcal axillary lymphadenitis.
  N Engl J Med
  . 1990;323:655–658.
  
• Henry PH, Longo DL. Enlargement of lymph nodes and spleen. In: LongoDL, Kasper DL, JamesonJL, et al., eds.
  Harrison’s Principles of Internal Medicine
  . 18th ed. New York, NY: McGraw-Hill;2012:465–471.
  
• Pasternack MS, Swartz MN. Lymphadenitis and lymphangitis. In: Mandell GL, BennettJE, Dolin R, eds.
  Mandell, Douglas and Bennett’s Principlesand Practice of Infectious Diseases
  . 7th ed. New York, NY: Elsevier/ChurchillLivingstone; 2010:1323–1333.
  
• Thomas KT, Feder HM Jr,Lawton AR, et al. Periodic fever syndrome in children.
  JPediatr
  .1999;135:15–21.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cellulitis
  
• Lymphangitis
  
• MRSA
  

CODES

• 289.1 Chronic lymphadenitis
  
• 289.3 Lymphadenitis, unspecified, except mesenteric
  
• 683 Acute lymphadenitis
  

BASICS

• Lymphangitis is the infection of lymphatics that drain a focus of inflammation
  
• Histologically, lymphatic vessels are dilated and filled with lymphocytes and histiocytes:
  
  • Inflammation frequently extends into perilymphatic tissues and may lead to cellulitis or abscess formation
    

• Acute lymphangitis:
  
  • Likely caused by bacterial infection
    
  • Most commonly group A β-hemolytic Streptococcus
    
  • Less commonly due to other strep groups, and occasionally
    Staphylococcus aureus,
    including resistant strains such as community-associated methicillin-resistant
    S. aureus
    (CA-MRSA):
    
    • CA-MRSA risk factors: Prior MRSA infection, household contact of CA-MRSA patient, military personnel, incarcerated persons, athletes in contact sports, IV drug users, men who have sex with men
      
    • Different antibiotic susceptibility than nosocomial MRSA
      
    • CA-MRSA now sufficiently prevalent to warrant empiric treatment
      
    • Suspect CA-MRSA in unresponsive infections or if multiple or recurrent abscesses
      
  • Other organisms:
    
    • Pasteurella multocida
      (cat or dog bite)
      
    • Spirillum minus
      (rat-bite fever)
      
    • Wuchereria bancrofti
      (filariasis): Consider in immigrants from Africa, Southeast Asia/Pacific, and tropical South America with lower-extremity involvement
      
• Chronic lymphangitis:
  
  • Usually caused by mycotic, mycobacterial, and filarial infections
    
  • Sporothrix schenckii
    (most common cause of chronic lymphangitis in US):
    
    • Inoculation occurs while gardening or farming (rose thorn)
      
    • Organism is present on some plants and in sphagnum moss
      
    • Multiple SC nodules appear along course of lymphatic vessels
      
    • Typical antibiotics and local treatment fail to cure lesion
      
  • Mycobacterium marinum:
    
    • Atypical Mycobacterium
      
    • Grows optimally at 25–32°C in fish tanks and swimming pools
      
    • May produce a chronic nodular, single wart-like or ulcerative lesion at site of abrasion
      
    • Additional lesions may appear in distribution similar to sporotrichosis
      
  • Nocardia brasiliensis
    
  • Mycobacterium kansasii
    
  • W. bancrofti