Acute Infectious Cervical Lymphadenitis of Children in A Tropical Country

Introduction: The volume increase of a cervical lymph node is frequent in infancy .It is most often secondary to a benign infection of the upper aerodigestive tracts [1,2]. It is a medical and surgical emergency frequently encountered in developing countries, despite the generalization of antibiotics. Its gravity depends on the virulence of the germ and the fragility of the patient. Patients and Methods: It’s about a retrospectively study of all the medical files records of patients under 16 years old hospitalized at the ENT department of Fann Teaching Hospital for the management of infectious cervical lymphadenitis . The studied period is January 1st, 2008 to November 30th, 2017. Results: We had collected 83 medical files of patients with acute infectious cervical lymphadenitis including 66 cases of suppurative acute lymphadenitis and 17 cases of simple acute adenitis (uncollected). The average age of our patients was 2.4 years with extremes ranging from 1 month to 16 month. The location of swelling was the submandibular region in 57 patients, upper jugular area in 8 patients and submental region in 6 patients. Stapphyloccocus aureus is the most frequent bacteria found in 29 cases. Initial antibiotic therapy consisted of the association of amoxicillin/clavulanic. A favorable evolution marked by an apyrexia after 48h of treatment with regression of the swelling and a resumption of the feeding was noted in 92% of the cases. We deplored two cases of death. Conclusion: Acute adenitis is frequent in pediatric otorhinolaryngology. It is often secondary to oropharyngeal infections, dental and skin diseases. The treatment is essentially based on antibiotics.


Introduction
The volume increase of a cervical lymph node is frequent in infancy .It is most often secondary to a benign infection of the upper aerodigestive tracts [1,2]. It is a medical and surgical emergency frequently encountered in developing countries, despite the generalization of antibiotics. Its gravity depends on the virulence

The diagnostic aspects
The time between onset of cervical swelling and admission ranged from 1 to 25 days with an average of 8.75 days. All our patients present with an inflammatory lateral cervical swelling, the other associated clinical signs were detailed in Table 1. An infectious syndrome was present at the time of diagnosis in 80.72% of cases. The location of swelling was the submandibular region in 57 patients (Figure 2), upper jugular area in 8 patients, submental region in 6 patients and not specified in 12 patients. Portal of entry was nasopharyngeal in 66.26% of cases, cutaneous in 7.3% of cases and in 26.50% of cases, it was not found. Three patients in our series underwent adenoidectomy. A cervical ultrasound was performed in 14 patients whose needle aspiration was unsuccessful. It showed suppuration in 6 cases and in the remaining 8 patients it showed cervical non-necrotic lymphadenitis. Biologically, leukocytosis was noted in 29 patients and the average CRP was 64.88 milligrams (mg) with extremes ranging from 12 mg/l to 216.13mg/l. A field assessment (glycemia, creatine, HIV serology) was performed in 14% of patients and was without particularities. Fine needle aspiration in all patients brought pus in 66 cases. Of these 66 samples, 56 bacteriological results were found. Isolated organisms were methicillin-resistant Staphylococcus aureus (n = 29), group A streptococcus (n = 9) and decapitated infection (n = 21) ( Table 2).

Therapeutic aspects
The majority of patients (61.44%) had received oral antibiotic treatment, based on amoxicillin and cotrimoxazole, prescribed in others hospital before admission. And incision with drainage under local anesthesia was performed in the cases where the tumefaction was collected. The average amount of drained out pus was 17.6 ml with extremes of 3 ml to 70 ml. Medical treatment alone was initiated in cases of uncollected swelling. Initial antibiotic therapy consisted of the association of amoxicillin/clavulanic acid with adjuvant therapy (analgesic, nasal lavage, and iron supplementation). The average duration of hospitalization was 5 days with extremes of 3 to 11 days. A favorable evolution marked by a stable apyrexia after 48h, a regression of the swelling and a resumption of the feeding was noted in 92% of the cases. However, we noted cases of complications like a necrotizing dermo-hypodermis's (n = 1) ( Figure   3), myositis (n = 1), keloid scar (n = 1) and one recurrence. In our series, two cases of death were deplored, the first case of death was a 3-month-old infant who presented a cervical lymphadenitis and a retropharyngeal abscess with a syndrome of severe respiratory distress motivating an emergency tracheotomy but the child already had hypoxemia and he died. The second case of death was septic shock with multi-visceral failure. Adenoidectomy with or without tonsillectomy was performed remotely within an average of 1.5 months after hospital discharge in 28% of cases.

The epidemiological aspects
Acute cervical adenitis is a common condition in tropical environments. It is often benign and is mainly of interest to the pediatric population. In our study, we found a median age of 2.4 years which corroborates the data of the literature [1,4,5]. The majority of patients in our series (89.15% of the cases) were under 5 years old. Beyond this age the incidence decreases sharply due to progressive atrophy of the cervical lymph's nodes, a decrease of upper respiratory tract infections secondary to maturation of the immune system [4][5][6][7]. Male prevalence found in our work (or 54% of the cases) is a statement shared with other authors [1,[4][5][6], without any physio pathological explanation that can be made to this observation.

The clinical and paraclinical aspects
The relatively long consultation delay is due to the fact that many patients go first to the traditional healers. This is explained by the substantial under-medicalization in our context and the low socio-economic level [4]. The classical clinical presentation is dominated by an inflammatory-type cervical swelling (pain, heat, redness) associated with an infectious syndrome [8][9][10]. These signs were found in all our patients. The association with acute nasopharyngitis at the time of diagnosis is frequent because it is most often the gateway. It is present in our work in 39.7% of cases which is consistent with the results of the literature [3][4][5]9,11].
Some nonspecific signs, such as general state deterioration, anorexia, and stiffness of the head, may be prominent in infants [11]. The existence of a fluctuation of ganglionic swelling is in favor of suppurative adenitis. Diagnosis of suppurative adenitis will be confirmed by the presence of pus during the fine needle puncture which opposes it to the acute adenitis not collected. When the ganglionic hull is thick because of a large peri adenitis, the diagnosis is more difficult [1,12,13]. Some authors recommend a systematic ultrasound to highlight the collection in the form of a hypoechoic pad with posterior reinforcement before considering an exploratory puncture of the ganglion [1,12,13].

Bacteriological data
A sampling of pus for bacteriological examination must be carried out before any antibiotic treatment because in all the series, a high rate of decapitated infection was found, including our study [1,2,4,10,11]. In the literature, the most frequently found germs are Staphylococcus aureus and Staphylococcus pyogenes which is consistent with our results [1,3,4,7,11,15,16] of a catheter to make other aspirations [1]. When adenitis is not collected, parenteral antibiotic therapy alone is performed. The first-line antibiotics used are amoxicillin-clavulanic acid, penicillin G, and third generation cephalosporins in combination with metronidazole [14,17,18]. This was the case of 17 patients with a simple adenitis in our series. The average duration of parenteral antibiotic therapy in our practice in case of surgical drainage is 5 days, which agrees with the data in the literature [1].

Conclusion
Acute adenitis is a common pediatric otorhinolaryngological condition. It is often secondary to infections of the oropharyngeal sphere, dental and skin diseases. The treatment is essentially based on antibiotic therapy combined with surgical drainage in case of purulent collection. The treatment of the portal of entry is imperative to avoid recurrence.